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. � City of 4rono - Building Permit Application for Maintenance / Replacement / R�model �i.�. i , �r , � � , r �r� �� tc, — ��` �. I } A> Maili»g Address: �''��Y� PO Box 86 Permitnumber: Crystal Bay, MN 55323-0066 bate receiverl: :✓C� Street Address: Received by: ��, � 2750 Kelley Parkway Plan teview fee: �' Orono, MN 55356 t��5 t3p�`� T�,F�: � y t . �r Main: 952-249-46� Fax: 952-249�4616 www.ci.wono.mn:us This appiication form must be compieted in fuli and all required infonnation must be submitted. Incomplete apptications will be returned. (P/ease prrnf} GEMERAL INFORMATION: Job Site Address: 3675 Narthshore Dr: Orono MN 55391 Wilt this be a Parade of Homes, Remodeters Showcase Home or other Display Home? Yes No !f yes,a special event pe�mit is requirBd wid►Police Deparhnent and City Couaci!approva!60 days prior to the event ShutHa bus service w/N be �quired unless app%rcant derrrrRonsfrates sulilcterrt on�ite pa�lcirrg is available. Non permitted events wii!not be apowed. CONTRACTOR/APPLICANT INFORMATION: Name: Reroof America Contractors MN State License# BG637481 F�cpiration Date: Q3131116 �ead Certification Number. NAT-1 Q292$-1 E�tpiration Date: Q2/26l16 (for work on homes that were canstructed pr�or to 1978 Phone: (celt) (of�ice) 952-88$-$440 Mailing Address: _10740 LVndale Ave. S. #10W ��ri= Bloomin�tan Z�P� 55420 Contact Person: Applicant is: XContractor / Homeowner tcir��a,e� Email andior Fax: �,��Q��reroafamerica com -fax#• 9�2-$,88-8414 PRt?PERTY OWNER INFORMATION: Name: Melissa Plachecki Phone(day}: �i12-806-5872 Address: 3�g5 Nc� hahor ' Dr ��xY� Orono Z�P: 55391 Email and/or Fax: ' " PROJECT INFORMATION. Overal► ra'ect descri t�on: Remove and re lace shin les on dweltin &shed Type of Project: Any earth movement may also requlre ❑Doar(s) ❑Remodel ❑Fire Damage MCWD review 8 permits: �Re-roof,asphalt ❑Repair ❑Storm Damage �innehaha Creek Watershed Distric!(MCWQ) ❑ Re-roof,cedar 18202 Minnetonka Blvd ❑Restaration ❑Water Damage Deephaven, MN 55351 ❑ Re-roof,ather(specity) ❑Siding ❑Other. (speafy} F'hone: 952-471-0590 Fax: 952-471-0682 ❑Wictdow(sj www.minnehahacreek.om Estimated Construction Valuation of Project(excludi�g land) $5 20.00 APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Suilding Department; • Certifies that the information supplied is true and correct to the best of hisfher knowdedge. The applicant recognizes that they are solely respansible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to rejed it un61 it is complete; • 8ome a' all of the infotmation that you are asked to provide on this application is dassified by State law�s either private or confidential. Private data is infarmation which generally cannot t�given to the public but can be given to the subject af the data. Confidential data is infarmation which generally cannot be given to either the public or the subjed of ttte data. Our purpase and intended use of this informat' n is to annually update our records and records of other govemmental agencies required by iaw. If ou refuse to su the' ation th li ion ma not be issued. ApplicanYs Signature: Date: 04/23/15 Owner's Signature: Date: Last,Updated.January 2015