2011-00801 - roofing - Laserfiche WebLink

Home Browse Search

� City of Or no • Building Permit Appiicatio for internal Work (windows, doors, sidin , re-roof, etc.) Mailing Address: Permit number: Og,D,jv.O PO Box 66 Crystal Bay, MN 55323-0066 Date received: 9 ,� �� , Street Address: Received by: �'.�, "� �ti�' 2750 Kelley Parkway Plan review fee: L�ESH04'� Orono, MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.o no.mn.us This app(ication form must be compfeted in full and all equired information must be submitted. Incompfete applications will be re urned. (Please print) GENERAL INFORMATION: . , Job Site Address: �(�� 5�pC �l� Will this be a Parade of Homes, Remodelers Showcase Home o other Display Home? ❑ Yes � No lf yes,a special event permit is required with Police Department and City Counci approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is ailable. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMAT�ON: , Name: L.�;�-(Z �r��c' � State License# p 3�,�'7SC Expiration Date: ,3 3� �zo�zr Lead Certification Number. �4 _ C, ��j�j_ j Expiration Date: 7 �p�� (for work on homes that were constructed prior to 1978 Phone: -7(03� y��_ ��D;:, (office) (ce�l) Mai(ing Address: ��c�� .�,�5�,;� �, S-�- City:/Ut � �-�l-��1 ZIP: ��r9 Contact Person: r� �s��-�.y, Appl cant is: � antra or / Homeowner (Circle One) Email and/or Fax: �-- PROPERTY OWNER INFORMATI N: Name: L l�L 2 r'}-gC.��— Phone (day): Address: �g ��jEs r2f� City:�2 (,� ��A-�� ZIP: �3 j�j Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage � 18202 Minnetonka Blvd ❑ Siding ❑ Restorafion ❑ Other. (specify) � Deephaven, MN 55391 Phone: 952-471-0590 �Re-roof ❑ Fire Damage Fax: 952-471-0682 www.minnehahacreek.orq Ovecall Project Description: Estimated Construction Valuation of Project (excfuding fand) $ ( �7�� — APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Buil ing Department; • Certifies that the information supp(ied is true and correct to the b st of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete appfication being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on his application is classified by State law as either private or confidential. Private data is informafion which generally cannot e given to the pubfic but can be given to the subject of the data. Confidential data is information which generally cannot b given to either the public or the subject of the data. Our purpose and intended use of this information is to annually upd te our records and records of other governmental agencies re uired b law. If ou refuse I the information,the a (ic tion ma not be issued. Appficant's Signature: Date: � G`f Z¢,( Last Updated: 03-01-2011