2012-00856 - roofing - Laserfiche WebLink

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/l � . . ��y �f C��-a�E� (��-� 2� �`�� ��`Ic�ing Perrnit A►pp6i�a�i�n �or t�Eair��er�ance l RenQva�io� (wi�aov�rs, c�oo�-s, siding, ��-roof, etc.) Mailing Address: 2��Z _�g'S� %�,d,�- PO Box o6 I Permit number: /Q � �� Crystal Bay, MN 55323-0066 Date received: 0— �-� '/ Z I/a � 'P�-�` a, ,� Street Address: Receiv�d by �� �� ,,��„��ti � 2750 Kelley Parkway � Plan��:review fee: � � � �s� �g Orono, MN 55356 I ESH� 'I Total Fee: • Main: 952-249-4600 Fax: 952-249-4016 www.ci.orono.mn.us This appfication rorm must be completed in fuli and all required inrormafion must be submitted. incompfete appficaiions will be returnecl. (Please print) GENERAL INFOR�ATI�t�: Job Site Address: I 2 Z�j ��,� � �-�- f � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ I�o I f yes, a specia/event permit rs required with Police Departmenf and City Council approval 60 days prior fo the evenf. Shuttle bus service wilf be required unless applicant demonstrates suffrcient on-site parking is available. Non-permitted evenfs wil/nof be allowea. CONTRA�TOR/APPLICANT INrOLRMAT101�: Name: n^ � .� a,�.�-1_ � f .( s. State License # �` �� -�'7 �r--T� , Expiraiion Cate: 2C�/`.( Lead Certificafion Number: Expiration Qate: (for work on homes that were construcfecl prior to 1978 Phone: . (0 3— y Z7- (ofiice) �o�� (��Z�7b2- 7��'� ) Maifing Address: s � L C�t � (c 6�„ Z1P; --3 �e � Contact Person: �� Applicant is: ontrac r Homeowner (Circie One) Ernail and/or Fax: PROPcRTY OWNER INFORMATIOH: G � Nam.,: � G � Ci('� c 1�s c?� Phone(day): 2 C73" y S��- 3 L+�7S " Address: S�,�v,--L_ City:.��nr�p ZIP: .'��o l.� Email and/or Fax PRaJ�CT INF�RM�4SIOf�: Type of Project: I /1ny earth movement rray require � � MCWD review& ermits: ❑ Door s ❑ Remodel ❑ Fire Qamage I Ninnehana Creek Watersh d District(MCWD) �Re-roof, asphalt ❑ Repair ❑ Storm Damage ! 1�202 Minneionka Bfvd ❑ Re-roof, cedar ❑ Restoration ❑V1�'ater Damage Deephaven, MN 55391 Phone: 952-471-Q590 ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (specify) I, Far.: 952-471-0682 � ❑Window(s) i www.minnehahacreek.orq II Overal{ Project �escriptioR: =sfirriated Construction Vafuafion o�Project (exciuciing fand) $ /� �� APPLICAMT ACKfVOWLCD�EM�t�T: • Agrees to provide all information required or requested by the Buiiding Department; • Certifies that the informafion suppfied is true and correct to the best of his/her knowledge. The applicant rerognizes that they � are soieiy responsible ror submit'ting a complete appfica'tion being aware that upon railure to do so, tne staff has no alternafive � ! but to reject it until it is complete; i • Some or all of the information that you are asked to provide on tnis applicatior is cfassified by Siate iaw as eitner private or confideniiaf. Private data is inforrrzation which generalfy cannot be given to the pubfic but can be given to tne subject of the I ; da.a Confidential daia is inTormafion which generalfy cannot be given io eitner the public or the subject of tne data. Our I ' purpose and intended use of this information is to annualfy update our records and records of other govemmental aqencies reauired by law. If vou refuse to suppfv tne information, tne aopfi�a'tion may not be issued. ApplicanYs Signature: Date: ��//Z Lzst Updated: OP�-D5-2011