2015-01290 - re-roof - Laserfiche WebLink

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► �� City of Orono Building Permit Application for Maintenance / Replacement / Remodel (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) �O� Mailing Address: Permit number: �f . s � v O PO Box 66 Crystal Bay,MN 55323-0066 Date received: � �o �� SfreetAddress: Received by: � y�, G�fi 2750 Kelley Parkway Plan review fee: ✓ t,9k�SHo�t� Orono,MN 55356 (�, Total Fee: �� - � `�' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: _ - _ _ __ ___ _ - —__ _- ---- _ __ ---- ---- - _ .._ Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No If yes,a specia/event permit is required with Po/ice Department and City Counci/approval 60 days prior to the event Shuttle bus s i e will 6e required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APS�CANT If�FO�TION: Name: ,�� U State License# �0� Expiration Date: 3,a�)—� Lead Certification Number: N�2�(�3��i Expiration Date: ��Z2�20 (for work on homes thaf were constructed prior to 1978 Phone: � G��QZ • G�, -'] (office) �,Q� . ' ��g'(.P Mailing Address: City:6}, y�,�s yK ZIP:�G,�-L(p Contact Person: �Z((, Applicant is: ontractor / Homeowner (Cfrcle One) Email and/or Fax: Z. 22. PROPERTY OWNER I O ATIO • � Name: - Phone(day): • Address: �/ City: ZIP: � Email and/or Fax: PROJECT INFORMATION: Overall project description: v�, ��(,�.(� Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑ Fire Damage MCWD review 8�permits: �e-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) .minnehahacreek.or Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information 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 application being aware that upon failure to do so,the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which gen ally cannot be given to the public but can be given to the subject of the data. intended use of this inf ann al p at our records and records of other govemmental agencies required by law. If ou refuse to su I e i rma the lica n ot be issued. ApplicanYs Signature: ,- " Date: l Owner's Signature: Date: Last Updated:January 2015