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+ . City of Orono Building Permit Application Mailing Address: o-�i j—� O.g,O,�.O PO Box 66 Permit number: Crystal Bay, MN 55323-0066 Date received: a� >, St►eet Address: Received by: �s,�, �titi 2750 Kelley Parkway Plan review fee: l��og� Orono, MN 55356 Total Fee: Main: 952-249�600 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 retumed. (Please print) GENERAL INFORMATION: Job Site Address: 3475 Livingston Ave. Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ✓ No ff yes,a specia/event permit is required with Police Department and City Council approva!60 days prior to the event. Shutt/e bus service will be required un/ess applicant demonstrates sutficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANt INFORMATION: Name: Ralphs Buildinq and Remodelinq L.L.C. State License# 20591644 Expiration Date: 03/31/10 Phone: (651)808-1818 (office) (cell) Mailing Address: 6090 312 th Street Citv: Stacv ZIP: 55079 Contact Person: Ralph Anderson Applicant is: Contractor / Homeowner �ci�o�,a� Email and/or Fax: PROPERTY OWNER INFORMATION: Name: Judy Allen Phone(day): (952)471-9825 Address: 3475 Livinqston Ave. Cjty: Wayzata Z�p; 55391 Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits ❑Door(s) �Remodel ❑Water Damage ❑Window s Minnehaha Creek Watershed District(MCWD) ( ) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 �Siding B Restoration ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 �Re-roof ❑Fire Damage www.minnehahacreek.orq Ovet'all ProjeCt DesCflptfon: Tear-off and Replacement of existin roofin Estimated Construction Valuation of Project(excluding land) s 15,000.00 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 altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is dassified 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 subjed of the data. Confidential data is information which generally cannot be given to either the public or the subjed of the data. Our purpose and intended use of this inforrnation is to annually update our records and records of other govemmental agencies required by law. If you refuse to supply�formation,the application may not be issued. .�`� Applicant's Signature: �',:,�/,� /' Date: 04/27/09 Reset Form �