2015-01511 - roofing - Laserfiche WebLink

Home Browse Search

Nov 27 2015 1220PM HP Fax page 1 • Vlty VI VI VI IV � ' Building Permit Application for Maintenance / Replacement/ Remodel (i.e. windows, doars, siding, re-roof, etc. - NO STRUCTURAL EXPANSIQN) � MailingAddress: i�- ,�- _ � , ,�/1is�� P4 Box 86 Permit number: _-� ;� � (j E � �� 'T� Cryst�l Bay, MN 55323-0068 Date received: ° �- 5� / � �, 11�� eetA[ldress: Rsceivedby: �'l a'� f r��._'� � V 2750 Kelley Paricway Plan review fee: `� L Orono, MN 55358 � t�Kf5H0�'� � R I�� -��1 � 7otal Fee: �� Main: 952-2�9-4800 Fauc: 952-249-4816 www.ci.orono.mn.us � �� This application form must be completed in full arrd all required intormation must be submitted. Incamplets appllcatlon�wlll be retumed. (Please prrnt) GENERAL INFORMATION: Job SFt!Addriss: � l G� �j �.�� Wilf thls b�a Pande af Homes,RemodN�n Showcase Home or other Dlsplay Harr�? Yes No N Yrot�a apecfa/evarrt permit rs reqwired wifh Potice Department and Clty Carrx�l a�roval BO days pnior to tha svenl. Shuttle bua mervice wdl be required unf�ss appliCAnt de►►ivristretes au�icient on-site pariring is aveileble. Non-permitted events wiF!nof be alfowed. CONTRACTOR/APPUGANT INFORMaTlO Name: �� , Stnte License� ;'t�� p��, a�Z�, Expiration Date: �.� �_ Lead Certification Number: �r/¢�- g^/� � Expiration Date: y 2, (for worlr on homas that wrn conatrucMd prlor to 197� Phone: (cell) /� --;��r � � j (office) �— Mailing Address: p „ City: �� ZIP: Contact Person: l .�,.� Applicant is: Con or ! Homeowner �c�ra.on.� Email and/or Fax: ' �4.��'y. � �,y,�,,�, � , ., _ -�r ,,�7� _ A PROPEFiTY OWNER IN ATION: �;-��{r��y�j �' Name: p,,,y� ��y • Phone (day): ��_._ s��,,� f��T ,f Address: , City: 2lP: ��''�� Email and/or Fax: PROJECT INFORMATION: Over�ll ro" descri tion: Typ�of ProJ�ct; Any�arth movement may also rpulrr ❑ Door ❑ Remodel ❑Fire Damage MCWD review i p�rmlts: e-roof,�sphslt ❑Rep�ir ❑Storm Damage Minnehaha Creek Watershed Oiatrict(MCWD) ❑ Ra-roof,cedar 18202 Minnetonka Blvd ❑Restoration ❑Water Qamage Deephaven,MN 55391 ❑ Re-roof,oth�r(ap�cxy� ❑Siding ❑01her.(specify) Phone: 952�171-0590 Fax: 952-471-0682 ❑Window(s) _ www.minnehahacreek.ora Estimat�d Conatructlon Yaluatlon of Project(excludln�land) S '��S � l�? APPLICANT ACKNQWLEDGEMENT: • Agrees to provide all infoRnation required or requested by the Building DepaRment; • Certifiea that the intormation supplied is true�nd correct to the best oi hialher knowledge. The applicaM recc,�gnizes that they are sol�ly responsible for su0mitting a complele application bei�g eware that upon failure to do so, the slaif haa no allemalive but to reject it until it is compfete; • Some �r all of the information that you are aaked to provide on this app(ication ia dassified by State law as aither private or confidential. Privat�data is information which generapy cannot be given to the public but can be piven to the sub}eat of the data. Confidenti�l data is ir�formstion whiCh gene� cannot be given 10 either the public or tha subject oi the data. Our pwpose and intended use of t�ia info ' is to annual update our recorda and rocorda of other gover ental age ciea required by law. It ou retuse to s i ortnation the i ion ma issued. ApPlicant'a Signature: � Date: / 1 �7 / Owner's Signature; Date: