2013-00517 - re-roof - Laserfiche WebLink

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- � � � l j. Cit of Orono ,�`�o� Y Bu�iding Permit Application for Maintenance / Replacement / Renovation ' (No structural expansion. Only windows, doors, siding, re-roof, etc.) � �O� Mai�iPO Bo�66� Permit number: � O ,,� Crystal Bay, MN 55323-0066 Date received: '� � � � Street Address: Received by: y G� 2750 Kelley Parkway Plan review fee: `� Orono, MN 55356 ��kFSH°��` Total Fee: `� _�x= Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us °.t 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: � �G�S �- Will this be a Parade of Homes, Remodelers Showcase ome or other Display Home? ❑ Yes No � If yes, a special event permit is required with Police Department and City Counci/approva/60 days prior 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/A PLICANT INFORMATION: Name: �} State License# � Expiration Date: �j ,3� / � ��. � Lead Certification Number: NaT-11 b�o�"l�'� Expiration Date: � �6 - � (for work on homes that were constructed prior to 1978 � Phone: (cell) /Z- �- 6�/ (office) �SZ -92S-6�S� � Mailing Address: -j�j � Z '� p City: � {� ZIP: "�- � Contact Person: Applicant is Contrac / Homeowner (Circle One) �° �� Email and/or Fax: S � op�,e� 0.O �,��.,,� �f Z - �S- d � K�, ;�;�� �:7 PROPERTY OWNER INFORMATION: Name: ��h,� �,(b` �' �� Phone (day): ��Z -�7� .- (�523 � .s; Address: �5C7 /`1i�h.�7�KG ,,�I-�'t�l�.��►�to.Q.s �..vt• City: Q ,�,vw ZIP: �3� � Email and/or Fax: �' � `��` PROJECT INFORMATION: Overall projectdescription: h� :,: :� Type of Project: Any earth movement may also require :��, MCWD review 8�permits: � ❑ Door(s) ❑ Remodel ❑ Fire Damage � `�Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) � 18202 Minnetonka Blvd j ❑ 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) www.minnehahacreek.orq nu � � Estimated Construction Valuation of Project(excluding land) $ 00• �C� $� �� 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 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 public or the subject of the data. Our purpose and �� intended use of this information is to annually update our records and records of other governmental agencies required by law. If � ou refuse to su I the' f atio the a lication ma not be issued. � � Applicant's Signature: Date: 5 �� — � 3 �� �, � Owner's Signature: Date: �; , Last Updated:03/06/2013 � ,,. . � a , ` .. ,,..,:.: �:. .. .... � , . . . -.. . .., � .... ., .. . . .. � . .. -...yS..u....'.