2013-01173 (Re-roof) - Laserfiche WebLink

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City of Orono ; - Bu�lding Permit Application for Maintenance / Replacement I Renovation (No structural expansion. Only windows, doors, sidin�, re-roof, etc.) �O� Mailing Address: Permit n�mber: �I3"'�GI� PO Box 66 0 Crystal Bay, MN 55323-0066 Date received: ��►`�-� Street Addr�ss: Receive �by: y� `�C'' 2750 Kelley Parkway Plan revi w fe lqkFSHO��,C' Orono,MN 55356 � / , Total Fe : � a 7 1 `�' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information nlust be submitted. Incomplete applications will be returr�ed. (Please print) GENERAL INFORMATION: Job Site Address: i �'� n ►�2�,p � �-r� ,-E-� ..� �i Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home ❑Yes � No !f yes,a special event permit is required with Police Department and City Council approva/60 days prior to t e event Shuttle bus service will be required unless applicant demonstrates s�cient on-site parking is availab/e. Non permitted ev nts will not be allowed. CONTRACTOR/APP ICANT INFORMATION: Name: 1 �G�n G � 1-c��v��Pl�� V�'('�.�j State License# �� ,� 7� � q Expiration Qate: Lead Certification Number: Expiration pate: (for work on homes that were constructed prior to 1978 4 Phone: (cell) 9�Z � (�g 1 - ��0 D (office) I�Z ' �Z� - Z �y $ Mailing Address: 2�by (��.�,� � y� City: �N� Z�„�z ZIP: j�� Contact Person: ��tic� �,��,,�� Applicant is: ract / Homeowner (Clrcle One) Email and/or Fax: �o F '� �C�� , w� w PROPERTY OWNER INFORMATION: � Name: -�t vv� �wt ��,�r�--I I, Phone(day): �� z � � �q q � Address: I Z7 o A��a- �i'i�� City: �,�.�7,�.�Q�- ZI P: ��3g I Email and/or Fax: PROJECT INFORMATION: Overall roject description: ��G Type of Project: Any earth ovement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MC review 8�permits: Minnehaha Cfeek Watershed District(MCWD) '�„Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage D�ephaven,MN 55391 ❑ Re-roof,other(speciiy) ❑ Siding ❑Other.(specify) PI'one: 952-471-0590 'ax: 952-471-0682 ❑Window(s) ww�v.minnehahacreek.or Estimated Construction Valuation of Project(excluding land) $ 31+ ��a D . � 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. T e applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do o,the staff has no altemative but to reject it until it is complete; �I • Some or all of the information that you are asked to provide on this application is classifi�d by State law as either private or confidential. Private data is information which generally cannot be given to the public but caj� be given to the subject of the data. Confidential data is i ormation which generally cannot be given to either the public or the s�bject of the data. Our purpose and intended use of this in rm ' n is to annually update our records and records of other gover�mental agencies required by law. If ou refuse to su I th i f ,af n,the a lication ma not be issued. I Applicant's Signature: Date: �I ► � �, . Owner's Signature: Date: Last Updated:03/06/2013 � �