2013-00826 (Re-roof) - Laserfiche WebLink

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-� City of Orono � • Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) �O�O Mailing Address: Permit number: PO Box 66 Crystal Bay,MN 55323-0066 Date received: Street Address: Received by: ��, `� 2750 Kelley Parkway Plan review fee: G Orono, MN 55356 �qkESHO�� Total Fee: 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 must be submitted. Incomplete applications will be returned. (P/ease print) GENERAL INFORMATION: Job Site Address: __(Z �1 ��c,� �✓� Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? ❑Yes `�No If yes,a special event permit is required witi►Police Department and City Counci!epprova/60 days prior to the event Shuttle bus service will be required unless applicant demonsirates sufficient on-site parking is available. Non permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: ��i Z��i,�.� ��S �� State License# (�� L �S C� F�cpiration Date: Lead Certification Number. Expiration Date: (for work on homes that were consbucted prior to 1978 Phone: (cell) (offlce) ClS Z- ��S—7ZZ CP Mailing Address: �,�,(�7 ��c�l;S�� (�- City: � �� pL„� ZIP: s�3 w� Contact Persorr. �=�� \�-e S S Applicant is: ontracfi / omeowner (Clrcle One) Email and/or Fax: �sz.-�Z�y �� PROPERTY OWNE�INFORMATION: Name: �� e� S�^ Phone(day): aSZ- 2.1t- �I`1 Address: 1271 /�w-h� S . City: �� ZIP: ��j ' Email and/or Fax: PROJECT INFORMATION: Overall pro�ect description: Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review�permits: �Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 Phone: 952�71-0590 ❑ Re-roof,other(specity) ❑Siding ❑Other: (specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora Estimated Construction Valuation of Project(excluding land) $ b APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certfies 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 applica6on 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 classfied by State law as either private or confidential. Private data is information which generally cannot be given to the public but c�n 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 information is to annually update our records and records of other govemmental agencies required by law. If ou refuse to su I th information,the a lication ma not be issued. Applicant's Signature: Date: � � / � OwnePs Signature: Date: Last Updated:03/06/2013