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Aug. 23. 2011 12, 59PM Giertsen Company No. 2611 P, 1 City of Orono _ Bu�ilding Perrnit Application for I�aintenance / Renavation � (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: - O�,�,�O PO Box 86 ' : Crystal Bay, MN 55323-0066 Dete received: �, Stieet Address: -Recelved:by:. �, � 2750 Kelley Parkway Plan:revlew fee: �kEsxo�� Orono,MN 55356 . Total Fee: Main: 952•249-4600 Fax: 952-249-4616 w.ww,ci.orono.mn.us . This application form must be completed in full and all required informafion must be submitted. Incomplete applications will he retur'ned. (Please p�Jnf) C�ENERAL INFOaMA710N: Job Site Address; �� Will this be a Parade of Homes, Remodelers S wcase Home or other Display Home? ❑Yes o If yes,a special event permit is requlred wlth Pollce Depar(merit and CJIy Councll approval BO days p�lor(o fhe evenl. Shutlle bus service will be roqulred unless applicant demonsfra(es sufl7clent on-slte parking Is avallab/s, Non-permllfed events will not be allowed. CONTRACTOR 1 ApPLICANT f NFORMATION: Name: ��`f��-S��/'1 �.D. State License# �7�/o Explratlon Date: '.�j-- 3�— �C� Lead Certlfication Number: NA-�j-'- 2 3'��--� Expiratlon Date: L�—S'—J�j (for work on homes that were cons�ructed 4rfor to 1976 � phone: 7(� �"— :�.,(v— /�.Q (office) (p�2`'7v � .,_ �5� � (cell) Mailing Address: �"5 0'� /�yv /1� City: ,� � zIP: � Contact Person: �r V/ y� �`f l Vj Applicant is: ntract / Ho eownet �c«�ia o�a� Email and/or Fax: lije U i vi � � 9 r�G r�S��Ge�- �m . PROP�RTY OWNER INFORMATION: Name: �/1lGLl�S'/ZZO� Phone(day): ��'a � Address: � 3�7p /��asi' � �oa� c�cy: n /...�� ziP: � � Email and/or Fax PROJECT IN�ORMATION; Type of ProJact: Any earth movement may requlre ❑Door(s) ❑Remodel ❑Fire Damage MCWD revlew 8�permlts: Minnehaha Creek Watershed District(MCWD) Re-roof,asphalt�a� Repair ❑Storm Damage 18202 Mlnnetonka Blvd Re-roof, cedar �oti5e ❑l�estoration ❑Water Damage deephaven, MN 553H1 Phone: 952•471-0590 ❑ Re-roof,other(6pecify� ❑Slding ❑Other:(specffy) Fax: 952-471-0662 ❑Window(s) www.minnehahacreek.or� Overall Project Description: /�'— p �� .�~-/''rj d Estlmated Construction Valuation of Project (excluding land) $ ��L��j� APPL,ICANT 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 hls/her knowledge. The appllcant tecognizes that they are solely responsible for submitting a complete appllcatlon being aware that upon failure to do so,ihe staff has no alternafive but to reject It untll it Is compleYe; • Some or all of the info�mation that you are asked to provide on this application ls classlfied by State law as e)ther private or confidential. Private data fs informallon whfch generally cannot be giveh to the public but can be given to the subject of the data. Confidentlal data Is Information whiCh generally cannot be given to eifher 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 governmehfal agencies re uired b iaw, )f ou refuse to su I t e Informatfo a lication ma not b�issued. � Aoolicant's SianatiirA: �.� a+A� ��/��