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06/21/2012 09:58 FAX 6517764378 HARRIS-ROOFING f�002/003 <br /> � • f <br /> City of Orona <br /> 6uilding Permit Application for Mainfienance / Re�ovation <br /> (windows, doors, sidin , re-roof, etc. <br /> Mei�ing Add►eas: Per1'rnt numDer_ � � . <br /> O�O�O Crygtal BaY.MN 55323�068 D�tac,�1Y� ' '"� " I <br /> street Address: Reo�ived till: <br /> �, � 2750 Kelley Parkvray Pten reyiew fee: •. .. <br /> ��o� Orono,MN 55356 � • . • . . . . <br /> r���: l3'1 ��5" . <br /> Main: 852-24S�d800 Fax: 952 249�616 www.a.orono.mn_us <br /> This applica�on form must be cornpleted in Tull and all rec�ed information must be submitted. <br /> incomplete applications will be�elumed. (Please print) <br /> GENERAI.INFORMATION: <br /> Job Sibe Address: ,3�J N d��' �(� � � V e <br /> w�l this be a Pardde of Hom�,Remodelc�s showcase Honre or atl��r Oi4pkq/Nome? Yes No <br /> IfYac�e specia�.venf Pem�a is re9�od w�PaNce D�erbnan�and G�Covx�l�proaal 60 days prla ro Me evrt Sf�iet►s pus ' w�l be <br /> �squi►bd u►�eas ePD�eM den►o►dr�tes sr�icient w►�Wie P�kiq is IYs�blr. Afon�pr/MmeO sv�w�ll not b•e�powed <br /> _ CON1'RACtOR/APPIICAIV'f INFORMATION: _.. _ _ <br /> Name: �QI'� C �S �00�'i YlA IYl C • <br /> Sfiate ucense� C'(�\q1���l � E�irabon Date: 3�31 3 <br /> Lead Certificatio� Number: Expiratlon Date: <br /> (!or woNc on homea d�at w�a�a consbucced prior to 1� <br /> Phone: �e 5 1 ll 1Q ��4 0 (o�ce) co�a �►3 a 3�o� � (cell) <br /> Mailing Add�ess: � S • C�� ctU 2iP� 5 51 0 <br /> Contact Person: Z eSS1 C C� }�0.r r 1 S A►PP���M�� ��� � Nol'ileowner �a�.one� <br /> Email and/or Fax: � S� �o ' • �em ' <br /> PROPERTY OWNER INFORMATION: <br /> Name: _ ��YYl 1.V��'� <br /> Phone(day): �5 a 3 <br /> Address: ��5'1 a �(V o Y -i-1n 1no v e '�r�v e City: 0 r 0►fl o z1P: 55 3 9 � <br /> Email and/or F�x <br /> PROJECT INFORMATION: <br /> �'YPe�P�� Any sartb movement may►equite <br /> ❑Fire Damsge M����►i pe�mlts: <br /> ❑Door(sj ❑Remodel Mnnehaha Creek Waterahed pistrid(MCWD) <br /> Re-roof,ssphalt ❑Repair ❑Storm Damaga 18Z02 Minne�tonks Blvd <br /> Deephaven, MN 55391 <br /> Re-roof,cedar ❑Resbrddon ❑Water Dartiage Phono; 852�171-0590 <br /> ❑Re�oof,oU�er(apeciryi) ❑Sidinp ❑Ofher.(specify) Fstc: 952-471-0682 <br /> ����s� vrww.minneh�hacreekor8 <br /> Overnll Pro ect De�scri " : O�y <br /> Estima�ed Conswuction Valuation of Project(ex�cluding land) � tQ 000 • 0 O <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provids all ir+fortnation requirad or requesbed by 1he BuildnQ Departrnsr� <br /> . Certiflss that the lniormstion supplied is true and t�ect Op the best of hislher loiowled8s. The epplicerrt recognizes thet they <br /> ere solely respor�sible fer submitlin8 a complete applica�ion being ewane iha�t upon f,0�ure to do so,iho staff has no al�msiove <br /> but to reject it unt�it is complete; <br /> • Some or atl of the i�formetion that you arc asl�ed tc pnwide o� fhis appl'ir,abon is dassified by SqRe law as either privete or <br /> corrfidenti�l. Privste dal�is iMormrion which yenerelly carmot be given to the pub�c but cen be given to the subject of the <br /> deca. Confids�rtial data is information which ge��erally CannoR be BiYen to eidter Ihe public or the wbject of ltte data. Our <br /> purpose and intendsd use o1 this informaaon is t4 a�xnrapy upde�e au reoord5 end records of o4her govemmae�tql <br /> e�genaes <br /> re ired b law. If ou reiusa to infamation Ihe ation not be iss�,ed. <br /> �°►PPlicanYs Signature: Cate: p�.� � o�.� <br /> I.ast Updated; 09•�9,2011 <br />