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APR/25/2014/FRI 10:52 AM Garlock-French FAX No, 612 722 9754 P. 002 City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) `,r PO Box 66 Mailing Address: Permit number: �' fe4VX) Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: ay 2750 KelleyParkway , GPlan review fee: Orono,MN 55356 "41,5 HO"' 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) GENERAL INFORMATION' ,/ Job Site Address: SIO I '( i,, d,r.� 44V / (201 ,'. �irJL/ .Ss39/ Will this be a Parade of Homes, Remodelers`- owcase tr.me or o er isplay Ho e? ■ Yes No If yes,a special event permit is required with Police De.artment and C Council approval 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/APP ICA INFORMATION: . Name: y p(� ' 4016h- State 01�, - State License# • C a0/ "2,, _ Expiration Date: 3/3/// Lead Certification Number. 09-1:23'99C/-/ Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) (office) Mailing Address: , 57= City:4, ,y , " ZIP: c6-.ye, Contact Person: ,, Applicant is: ontrac o• / Homeowner (Circle One) Email and/or Fax: . �� A/7 i e/1. 1 • PROPERTY OWNER INFORMATIO Name: ��l�.trf" G� NLr f... Phone(day); ( /42- 7 y -006 Address: /l0l� �7/, �...� .ir% _ 4��!rj; City: j(EZIP: 515-011/ Email and/or Fax: i Tear off and replace flat roof section of house,using tapered isocyanurate insulation and Carlisle 60 mil EPDM PROJECT INFORMATION: Overall project description;_ . Type of Project: 1�ny ea(�movement may also require ❑Door(s) CI Remodel ❑Fire Damage r]tCWD review&permits: ❑Re-roof,asphalt ❑Repair . El Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑Re-roof,cedar 0 Restoration 0 Water Damage Deephaven,MN 55391 J.Re-roof,other(specify) ❑Siding Di Other:(specify) Phone: 952-471-0590 EYDP1Fax: 952-4'71-0682 ❑Windows) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ 5e) 0,97 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 you refuse to supply the informatio 1 the application may not be issued.• _ Applicant's Signature: 'it i fi 1, Y Date: /� Owner's Signature: I Date: Last Updated:03/06/2013