2014-01112 - roofing - Laserfiche WebLink

Home Browse Search

� City of Orono ' Building Permit Application for Maintenance J Replacement / Renovation (Mo structural expansion. Only windows, doors, siding, re-roof, etc.) � �� 4 Mailing Address: D/ — O/// �`�� PO Box 66 Permit number: � � O %/ o `' Crystal Bay, MN 55323-0066 Date received: � � � '� Street Address: Received by: � �� t�.: � �j � ,. � ; 2750 Kelley Parkway Plan review fee: \1.��.��,;/ Orono, MN 55356 /j_ -�-- Total Fee: j�� Main: 952-249-4600 Fax: 952-249-4616 �rrr�v✓.ci.orono.mr�.�is � 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; ,_� ,,�,_� �/i'�n� �� 'Lf� Will this be a Parade of Homes, Remodelers Showc,a�e Home ar other Display Home? Yes �W'o /f yes,a specia!event permit is requrred with Po/rce Department and Crty Council approva/60 days prior ta the event. 5huttle bus serv�ce w�!!be reguired un/ess applicant demonstrates su�cient on-site parking is avaitable. Non-pennitted evenfs wil/not be alfowed. CONTRACTOR/APPLICANT INFORMATION: Name: 1� a��!V� `�'��tt��(1;%�;,/t�J,e , State License# ` - Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 9378 Phone: (cell) �� "'�<« �'' �.� � � , �_ ��_�L�>.J (office) -�, l�� CUl Mailing Address: � " �'� �� , r , � ,� City , '�- �� ZlP: � � Contact Person: ,� i t� �t1 Applicant is: Contractor / omeowner �ci�cie o�e> Email and/or Fax: �<' � �� (� �' � �,, ; ,�" r��' �� PROPERTY OWNER(NFORMATION: Name: i -, �( -, s'�-?'��!� �� n�, Phone(day): � < � r��r':;�; � Address: � `"� � J �^�r;7,n `��/if'l Gity: �� U ' ZIP:�.,�C�� Email and/or Fax: �� j�� ,-, �� -�� PROJECT INFORMATION: Overall roject description: Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permlts: ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) ❑ Re-roof,cedar ❑ Restoration 18202 Minnetonka Blvd ❑Water Damage Deephaven, MN 55391 �Qe-roof,other(speciry) ❑ Siding ❑ Other� (specify) Phone: 952-471-0590 C��--�,n�,�--� F�: 952-471-0682 - ❑Window(s) vn�nro mir�neliahacreek.org 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 app(icant 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 pri�ate 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 th� public or the subject of the data. Our purpose and i intended use of this information is to annually update our records and recards of other governmental agencies required by law. If ou refuse to sup I the information,the a lication ma not be issued. ApplicanYs Signature: �} ��1t1CtIM�1 Date: � � Owner's Signature: i�"�`�-SH �c�t��C1M,V1 Date: �� Last Updated:03/O6/2013 _._. ____—__ ��z''YC- Tti-S G . . F�C'i'�____�_��V� 1''� � o��j��e (�-�n v►�- T �� �G-