2013-01101 - roofing - Laserfiche WebLink

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,r- � � - �t£�r ?,..--x"a � 7s. , -�s'�'^"vgr��_' s.�'"�sr-^� _ . _ . . . . „�� , .�.,�?. � ` City of Orono �-` Buiii�ing Permit Application for Maintenance / Replacement / Renovation � (No structural expansion. Only windows, doors, siding, re-roof, etc.) � � �O� Mailing Address: � _ � : PO Box 66 Permit number: '�� Crystal Bay, MN 55323-0066 Date received: j} — — � �`. � �� ' Received by: � E,�� Street Address: � � .; y� �` 2750 Kelley Parkway Plan review fee: � L Orono, MN 55356 � � �e��D `�KFSHO � 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) t ;' GENERAL INFORMATION:. _ � � `�; Job Site Address: ji`> L�/(.(, L(!�; �(��,� . Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o v;;, If yes, a specia/event permit is required with Police Department and City Council approval 60 days pnor to the event. Shuttle bus service will be � required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ,�, � CONTRACTOR/APPLICANT INFORMATION: . Name: j�'l�l�� -�'c. (`�pP�% • �.. State License# b�j�� Expiration Date: � Lead Certification Number: r.;,q�j (� �� _ � Expiration Date: (for work on homes that weie constructed prior to 1978 Phone: (cell) (office) �(,��-�(� �j- �J C� c� ` � Mailing Address: S� j�1/�J j�/� S o City: � �✓ ZIP: � S��`` �.,= Contact Person: Applicant is: ontG''� rac�/ Homeowner (Circle One) ��°` Email and/or Fax: P;_'- , PROPERTY OWNER INFOR ATION: � � Name: �� mL Lnl/l�' : s�; Phone (day): �js L� �f�IS ` /��'`� � ,,,� Address: 'Z� (,,�X,L U�✓�; ��,,�� City: �l��i..�p.�J ZIP: S S 5�) C�Y: Email and/or Fax: � �..r': �.,,. PROJECT INFORMATION: Overall pro�ect description: � 6� ' �'�t�� Type of Project: Any earth movement may also require �; ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: � ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ��= ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �N ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora �� Estimated Construction Valuation of Project(excluding land) $ c� � �.: � � ��e� APPLICANT ACKNOWLEDGEMENT: Q�,. � • 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 A�, 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 enerall cannot be iven to either the ublic or the sub ect of the data. Our ur ose and �.,� 9 Y 9� P 1 P P � intended use of this informat' n is to annually update our records and records of other governmental agencies required by law. If �> ou refuse to su I t info a on, e lication ma not be issued. ,��:,: Applicant's Signature. Date: � Owner's Signature: Date: ��`� Last Updated:03/O6/2013 �,,-: