2011-01535 - roofing - Laserfiche WebLink

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i � $ � . . .+�.�� . ��" �,fi.�a �i�� f}� �i"4�'10 ..�.��..��: �. �uii�iing Permit �ppiica�io� for IV�ain�e�a�ce / f�enQ�a�ion = � ;. (windows, doors, siding, re-roof, etc.) F a ' M,ailing Address: � ` ' �0,� PO Box 66 Pecmit number: �/ J_ / -rj,�j � �_ 12 , /� Q Crystal Bay, MN 55323-0066 Date received: / 3 I ��a � ��:,�,� a, � Street Address: Received by: `� ��c, `,,,s',�„'�, G/ 2750 Kelley Parkway Plan review fee: �' \L�.rrESHro�� Orono, MN 55356 �; { Total:Fee: �U�j S� '� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ' ` $� This appfication 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: �7� �� j Will this be a Parade of Homes, Remodelers Showcase Home or other Disp�ay Home? ❑ Yes ❑ No � �� � If yes,a special event permit is required wifh Police Department and City Council approval 60 days prior to the evenf. Shuttle bus service will be ��-� required unless applicant demonstrates suffcient on-site parking is available. Non-permitted events wil/not be allowed. "� NTRACTOR/APPLICANT INFORMATION: f=•; Name: (��/al� �G��]S't-(Lc�c�'tc�„ � State License# C� �3 l,r7 �! Expiration Date: ? �i r-y "�^� Lead Certification Number: � �'��„��_. � Expiration Date: -� �,�" _ � (for work on homes fhaf were constructed prior to 1978 � Phone: 7�c.�- �7`�- �'�'/c-o (office) ' (cell) :� Maifing Address: ��-� c�l� ��L �-t— City: c�� 114ZIP: �-?� ��` � Contact Person: ��i2�� Applicant is: Contract ! Homeowner (Circle One) � Email and/or Fax: �;: PROPERTY OWNER INFORMATION: � Name: f�']1(��. �-«- T3C:12TS�� r� Phone (day): 4 { Address: �'7 5' C.:r�r � Cit : �n � - ZIP: � ' y �_/�.c��c., t� � ;I Email and/or Fax � �� PROJECT INFORMATIDN: Type of Project: Any earth movement may require � � � ❑ Door(s) ❑ Remodel MCWD review& permits: �� ❑ Fire Damage �;; 1 Minnehaha Creek Watershed District(MCWD) � : I �Re-roof, as halt ? p ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �� ❑Re-roof, cedar ❑ Restorafion Deephaven, MN 55391 �� i ❑Water Damage Phone: 952-471-Q590 �' a � ❑ Re-roof, other(specify) ❑ Siding ❑ Other: s eci �`� < �. � P fi') Fax: 952-471-0652 ;� www.minnehahacreek.orq �� t ❑Window(s) �� � r�� Overall Project Description: ��y}� �i�' ` ��.�a� �, �} Esfimated Construction Valuation of Project(exciuding landj $ ��spp i '�� s r � APPLICANT ACKNOWLEDGEM�NT: � � �� �.I • Agrees to provide all information required or requested by fhe Building Department; �� • Certifies that the information supplied is true and correct to the best of his/her knowfedge. The applicant recognizes that they are solely responsible for submitting a complete app(ication being aware that upon failure to do so, the staff has no altemafive � but to reject it until it is complete; • Some or all of the informafion that you are asked to provide on this appfication is cfassified 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 information which generally cannot be given to either the pub(ic or the subject of the data. Our A`� purpose and intended use of this information is to annually updaie our records and records of other governmental agencies �� re uired b law. If vou refu su I e information,the ap ficafion mav not be issued. � � � � Y.S AppficanYs Signature: �, Qate: �' � i � �� N � ,� Last Updated: OS-Q9-2011 �; � . _, :, . ._ _.. ... ,,k°iil