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. 0�/16/2015 16:36 9524738080 DALBEC ROOFING � PAGE 62/02 City of �rono �� D C�Cp �i,3 � Building Permit Applicatior� for Maintenance / Replacement / Remodel (I.e. wFndows, daors, siding, re-�oaf, etc. — NO STRUCTURAL EXPANSiON) Mailing Address_ �'� �_ �� Po Bux 69 Permit number. (�/ �� l �-J� � Crystal Bay,MN 55323-0466 Dete recefved� �� — I`�_=; a St�et Address: RPr.PI�PcJ hy� ? �^�, � 2750 Kelley ParkwBy Plan review fee: - � t,�k�sWQ��,� Orono,MN 55356 � � s � �� Yota� Fee: �`"l `�j , / �,-. ,�'� Main: 952-249-4$00 Fax; 852-249-4616 wv�w.ci,orono.mn.us �� This application form must be completed in full and all required information musf be submitted. � Incomplete appll�at�vns wnl be returned. (Please print) t 'n�`-' � G�NERA�, INFORMATION: I�M , �ob site Address: Will thls be a Paratie of Homes, Remodelers Showcase Home or other Display Hame? Yes No ff yes,a speclal event p�mtit is requbed wlth Pol'roe pep�rfinerrf and City Council approva!60 days p»pr to the event. Shuttle bus ice will ba requfred�nless appGcant demonstrates sufficient on�srte parkrng is aVBilable. Non-permined�vents will nOt be 9110wed. CON�'RACTOR/APPLICANT INFORMATION: Name: M�NT ��FItJ �� IN�, 5rate L�cense t� ��A��j��i Expiration Date: �30 Lead Certification Number: N�,� Expiration Date: N�A (f»�work on hom�s u►at xroro constructed prior M 7978 Pr,one: (ce�q - - (office) q5a� Mailing Address: r"j City_ ZIP; Contact�erson: Applicant i Contractor / Homeowner (ClrclaOne) Emaii and/or Fax: � r � PROPERTY OWN�R�NFORMATION: Name: ��LS'[�I N�� -- Phone(da}/�: q�a-4-Y1- �153 ,., Address; ��l BLA 1 N� Av� City: �� ziP: 5539 I Finail and/or Fax: �iF�l"1G�vc ��STfN(� F N � �Of� k- PROJE,C7 INFORMA7iON: Overall pro'ect descri tion: T T f-O �5� 20� �Z rU�-�Y /�'DKC�C� rype of Project: Any earth movement may also require rrnc�i ❑Doar(s) ❑ Remodel ❑Flre Damage M�WD revlew&permlts: �-�� ❑Re-ro0f,aspnarc �Repair U StDm1 DamBge Minneheha Creek Watershed Dis4rict(MCWp} 18202 Minnetonka Btvd � Re-roof,cedar ❑Restaration ❑Waler Damage Deephaven,MN 55391 '�Rc-iovf, ot e�(speclf� ❑Sltling �Vthe�: (speClly) Phone� 652�171-0590 Fax: 952-471-OQ82 �-'�' ❑window(s) �C�� wnvw.minnehah�Cr�ek.or4 �st�mated Constr ct n Varuation oi Projeci(excluding lanq) $ b APPLIGAN7 ACKNOWLEDGEMENT: • Agrees to provide all information requlred or requested by the Building Department; ! • Certlfles that the intnrmation supplled fs true and correct to the best of his/her know�edge. The applicant recognizes that they are soteiy responsiUle for submiiting a complete appncatlon peing aware that upon tailure to tlo so,the staff nas no altemative but to reject li until it is compl�te; • SnmP �r All nf 1he infoRnaGon that you are asked to provide on tnis applicatlon Is claseifiad by Sta4a law as 0ithar privaie or confidential. Private data is information which generally canttot be given tp the publiC but can be given to the subject of the data. Confidential data is Informetion wnicn generally cannot be given to either the publlc or the subject of tne data. 4ur purpose and If1t2�1Cjed USe OS YI113 I�OfTT12tlOf1!R}C1 aT71�IlAlIY 1141fJAiP.Alll'fPfftiric Ar1f1 YP.r_nrri¢nf nThRr r�nvprnmantal 2�anrlp�requ�rpd hy I&w. IS du refuse to su I the information,t not be issued. Applicant's Signature: - Date: Owner's Signature: bate: _ _ I ast Il��lalpd�.IanuAry 2015 �