2014-00956 (Re-roof) - Laserfiche WebLink

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� City of Orono � ��1 . Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) O Mailing Address: Permit number. p7f�/ - � � NO PO Box 66 Crystal Bay, MN 55323-0066 Date received: �' 02�O-J Street Address: Received by: y� ��C'' 2750 Kelley Parkway Plan review fee: � Orono,MN 55356 tRkESH��w Total Fee: �_�j� Main: 952-249�600 Fax: 952-249-4616 wnrow.ci.orono.mn.us �/�' " "�' This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION:�� I Job Site Address: � �� �11 this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o ►f yes,a special event permit is required with Police Deparfinent and City Council approva/60 days prior to the event. Shutde bus servi�will be requirad unless applicant demonstrates sufficient on-site parking is available. Non�ermitted events will not be allowed. CONTRACTOR/APPLICA�FORII�IATI0�1: Name: (e�i�.� State License# � Expiration Date: Lead Certification Number. g�� - Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) h (office) t Mailing Address: P�� j2, C' � ZIP: Contact Person: ��,�,� Applicant is. Contractor / Homeowner �cir��e o�a� Email and/or Fax: PROPERTY OWNER INFORMATIOPI: Name: -�� JI[�� Phone(day): � L • c9 - 3 Address: Z9� City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall ro'ect description: Type of Project: My earth movement may also require ❑ Door(s) ❑Remodel ❑ Fire Damage MCWD review 8�rmits: .�Re-roof,asphalt ❑Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55381 Phone: 952-471-0590 ❑ Re-roof,other(spectTy) ❑Siding ❑Other: (specify) Fax: 952-471-0682 ❑Wndow(s) www.minnehahacreek.ora Estimated Construction Valuation of Project(excluding land) $ D 0�• '— APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confiderrtial. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this info ation ' to n update our records and records of other govemmental agencies required by law. If ou refuse to su the i rm i n, a ion ma not be issued. Applicant's Signature: Date: �� P Owne�'s Signature: Date: Last Updated:03/06/2013