2011-00265 - re-roof - Laserfiche WebLink

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. � City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) MailingAddress: Permitnumber: U��b� �I O.��,�.0 PO Box 66 Crystal Bay, MN 55323-0066 Date received: � 29 � � � Street Address: Received by: 2750 Kelley Parkway Plan review fee: ��og�� Orono, MN 55356 Total Fee: //�/� �5 Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ( �/V� This applicadon form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (P/ease print) GENERAL INFORMATION: Job Site Address: � �:�� 1��',S �°� �� Will thls be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No If yes,a speaa/event permit is required with Police DepaRment and City Council approval 60 days prtor to the event. Shuttle bus service will be required unless applicant demonsGates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: �/ Name: /�;�G✓l5�` �OmF�� S��f 1�,/i'�1�0(� Ln� State License# ;�p p/p a 7 7 Expiration Date: �3/3/,�a �� Lead Certification Number: Expiration Date: (for work on homes that w�ere construc�prlor to 1978 Phone: 76 3-�/a� 7'q�O9(v (office) 76 .3 a�gO- /.3a � (cell) Mailing Address: (� ,S'/ �Qr-�,pr C�- City: �!� vL ZIP: S"s3 6 q Contact Person: �ryn/i �Q�G� Applicant is: on actor / Homeowner �ci��.o�� Email and/or Fax: 763 - y a 7- J�pO/ PROPERTY OWNER IN,�ORMATION: / � Name: !<�� ,u� ��/u��(�r� Phone(day): Address: !� y�<j ��,,b�P S{z�� C�{- City;/y�4 Gr�i�"�2 c.ti' ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑Remodel ❑Water Damage MCWD review 8�permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Siding ❑Restoration ❑Other:(specify) Deephaven, MN 55391 Phone: 952-471-0590 ❑Re-roof ❑Fire Damage Fax: 952-471-0682 www.minnehahacreek.orq Overall Project Description: Estimated Constructlon Valuation of Project(excluding land) S , � APPLICANT ACKNOWLEDGEMENT: Agrees to provide all infortnation required or requested by the Building Department; Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete appliqtion being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; � Some or all of the informabon that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is informatlon which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our recorcJs and records of other govemmental agencies r uired b law. If ou refuse to su I the information the a lication ma not be issued. ApplicanYs Signature: � '~ Date: �`"�� �ascupdaced: os-o�-20��