2012-00881 - roofing - Laserfiche WebLink

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�� f �� ��i�ing Pe�e�� Appii�a�iQn �€or tV�air��e�a�ee / RenQ��ic�� � (wic�aov�s, c#oars, siding, re-roof, e�c.} . Mailing Address: j�w 0 PO Box 66 � ��Permit nurriber. � � � � �� Crystal Bay, MN 55323-0066 , Datexeceived: �� > � � � � � I�� `� a. i Street Address: Received by: \'��n t�"'`ro'�, �,� 2750 Kelley Parkway � Plan.review fea: \�9g�s��`�,� Orono, MN 55356 � ( Total Fee: Main: 952-249-4000 Fax: 952-249-4016 www.ci.orono.mn.us This appiication form must be completed in Tull and all required information must be submitted. incompiete appfications will be returned. (Please print) ucN�P.AL INFOR�ATIO�l: � Job Site Address: 30� C��S C o -P� , y� Will this be a Parade of Homes, Remodefers Showcase Home or other Display Home? ❑ Yes �(No !f yes, a special even,permif rs required with Police Deparfinenf and City Council approval 60 days prior to the event. Shuttle bus servrce wil!be required un/ess appficanf aemonstrates sufiicienf on-site parking rs available. Non-permitted events wil/not be allowed. CONTRACTOR/APPLICANT INFORMATIOh: Name: ('�1�,r� Sce.s ho r� ��c�-.s'f'- S;ate License # C 2 3SG3�3 Expiration Date: G'3 �3 l l3 Lead CertiTication Number. (�/�-1- _ 1 "Z �,�,��, ) Expiration Cate: 6 ( 2� � � (for work on �►omes that were construcfed prior fo 1978 Phone: � 6 3- �32 - '3 t.6 (ofrice) (cell) Maifing Address: �S Z3 �I c,� � rc� Cit : �{-f-ti[� ZIP: SS�� j Contact Person: /YZ,�� c 5�� ,,�� F�,pp(icant is: ` Contractor / Homeowner (Circle One) Email and/or Fax: � PROPcRTY OWNER INFORMATIOt�k: Name: _'��c �'�'KnZ: S Phone(day): . Address: City: ZIP: Email and/or Fax PROJcCT INFORMf�oTIORE: Type of Project: ! lany earth movement rray require ❑ Door s ❑ Fire Qamage M^WQ review& ermits: ( ) ❑ Remodel I � P Minnehaha Creek Watershed District(MCWD) �Re-roof, asphaft ❑ Repair ❑ Storm Qarrfage 15202 Ninnetonka Bfvd ❑ Re-roof, cedar ❑ Restoration � ❑V�,'ater Damage I Deephaven, MN 55391 � Phone: 952-471-Q590 ❑ Re-roof, other(specify) ❑ Siding I ❑ Other: (specify) '; Far,: 952-471-Oo82 � ❑Window(s) I � www.minnehahacreek.orq � Overall Pro�ect Descnption: � �stimated Construction �faivafion os Project (excfuciing fand) $ l y v .� �• APPLICAI�T ACKiV0111lL�D��McNT: i • Agrees to provide all inrorrnaiion required or requested by the Building Depariment; • Certir'ies that the information suppfied is true and correct to the besf of nis/her knowledge. The appiicant recognizes that tney are solefy responsible for submit�ing a compiete appfication being aware that upon failure to do so, the staff has no alternative but to reject it unfif it is complete; • Some or all o`the inrormafion that you are asked to provide on tnis application is cfassified by State law as eitner privaie or � � confideniial. Private data is information wnich generaliy cannot be given to the pubfic but can be given to the subiect of the i da.a. Confidential data is information which generalfy cannot be giver to eitner tne pubiic or the subjecf of tne cata. Our I � purpose and intended use of this inrormation is to annualfy update our records and records of other qovernmental agencies I _ required by iaw. If you refuse to supofy the inrormation tne appiicafion mav not be issu d i Appfi�anYs Sigrature: �� jc� Date: � " �" I Z �ast Updated: 0�-d9-2D11 `