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Jun 16 11 01,25p Minnesota Roofing 763-208-7879 p.� <br /> 1 � :� . , <br /> Ci#y of Orono <br /> Building Permit Application al Work <br /> (windows, doors, si ng, re-roof, etc.) <br /> ��—\ Mailing Address; ermit number, <br /> j� �� PO Box 66 <br /> !O � ��`, Crystal Bay, MN 55323-0066 Date received: <br /> �� SfreefAddress: Received by: <br /> (�a �, �::`+' �. � <br /> \\�,�, ' '- �^� G�/ 2750 Keliey Parkway Plan reviewfee: <br /> ���kESKa4,,� Orono, MN 55356 <br /> Total Fes: <br /> Main 952-249-4600 Fax: 952-249-4616 uvvvw.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL lNFORMATION: <br /> Job Site Address: DO � 1�f <br /> Will this be a Parade of Homes,Remodelers S owcase Home or other Display HomeT Yes ❑ No <br /> !f yes,a specia�event permit is r�quired wrth Police DepaRment and City Council approval 60 days pnor fo the event. Shutfle bus servlce will be <br /> required unless applicant demortstrates suf/icient on-site parking is available. Non-permitted events wrll nof 6e aJlowed. <br /> CONTRACTOR/APPLICANT FORMATION: /� / <br /> fVame: �fd �1�/� � /Ge.s�o dP/..ri� <br /> State License# -' Expiration Date: 3 _ 3/ -�Z <br /> Lead CertiFication Number: �}T f Or O(3 - � Expiration Date: 2. �z - Zo/G <br /> (tor wark on homes that were constructed prior to 1978 <br /> Phone: ��,� �08' -�g � c� _ (office) _6� 6,� Q �� (cell) _ <br /> Mailing Address: p f}iee��n U ��tY= � ,v A�+e Z�P= � SS5�28 <br /> Contact Person_ �'�aN 5.�,,ty�-`� Applicant is; ontractor / Homeowner �CircleOne) <br /> Email and/or�ax: de n c�n ro��,�,a � (/�ahoo . Co++� <br /> T—'— <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��ei�l� �fhU�3'e�r <br /> Phone (daY): �SZ y7� Z!f 9 <br /> Address: ?,,,L�po r3,g..•,s. n 2 (�ie,, City: Q�QO,tI� ZfP: JrS'3 S� <br /> Email and/or Fax <br /> PROJECT �NFORMATION: <br /> Type of Project: Any earlh mavement may require <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCW�review 8 permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> �Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka 81vd <br /> ❑Siding ❑ Restoration ❑ Other: (spec�fy) Deephaven, MN 55391 <br /> P h o ne: 952-4T 1-0590 <br /> ,�Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ $'p,t70U <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to pr�vide all infortnation required or requested by the Buifding Department; <br /> • Certifies that the inforrnation supplied is true and correct to the best of his/her knowledge. The applicant recogn�zes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternabve <br /> but to reject it until it is complete; <br /> • Some or'alf of the information that you are asked to provide on this applicatian is classified by State law as either private or <br /> c�nfidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annuafly update our rec,Qrds and records of other governmental agencies <br /> re ulred b law. If ou refuse to su I the i rmation the a ticatian ma not be issued. <br /> Applicant's Signature: � Date: ,�— �.6— �o/! <br /> Last Updaied: 03-01-2011 � �� <br />