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Jun 05 17,07:40a p,1 <br /> ' City of Orono <br /> uilding Permit Application for Maintenance 1 Replacement I Rem�del — Residential �NLY <br /> (i.e.wi�dows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSlQN} <br /> �O A T Mailing Address Permit number: ��'/ 7 �- (��� >C'�j <br /> iya P09ox66 <br /> / Crystaf Bay,MN 55323-0066 Date recetved: ������/ 7 <br /> � <br /> ; Received by: � <br /> Sfreet Address: <br /> 1 ti � 2750 Keiley Parkway Plan review fee: <br /> `�� �,�' Orono,MN 55356 <br /> �kES H 04` r.� <br /> i otal Fee: t�'L� <br /> Main: 952249-4500 Fax: 952-249�616 www.ci.orano.mn.us ���,� <br /> This application form must be completed in full and aIl required inf�rmation must be submitted, <br /> fncomple#e applicatiuns will be returned. (Please print) <br /> G N�RAL INFORMATION: <br /> J b Site Address: d�(t�j '�h'�r�L 2x�--�� '�7,�-� (.,L���7�}Z �►i� �',�''U 1 <br /> ill this be a Parade of Homes,Remod ers Showcase Home or her Display Home? �Yes No <br /> !f yes,a specia!evenf permit is�equired wrth Poiice Depanment and City Counci!approval 6D days prior to ihe event. Shunle bus serv�ce wk!6e <br /> required unless applresnt demonsbates su�cient on-sife paiking is available. Norr yermrtted even[s wilJ not be allowed. <br /> C NTRACTQR f APPLICANT INFORMATION_ <br /> N me: � �iG�1 <br /> S ate Li�ense# �L�����c� Expiration Date: <br /> L ad Certification Number. �- ; �T��+�u�� <br /> ,��'r�'7��_,,�;-.� Expiration Date: Cj�_���,'X,� <br /> (for work on homes thaf were constructed prior to 19T8 <br /> P one: (cell) (office) '�r�—y47—�.�.}t� <br /> iling Address: ti � �, f' City� �j ZIP: �'� <br /> C ntact Person: Applicant is: ontractor l Ho eowner (Circle One) <br /> E ail andlor Fax: �n.c� �}���..`��-�•�� ' 4_ �?�`c:�Ct- �4,� , .` <br /> P OPERTY OWNER INFORMA7lON: <br /> I�t me: { h , t.,� � <br /> P one(day�: - ;_ <br /> A dress _1R1C1 ���1�-C�' �� CitY:�l j�#.�.�_'��. ZIP: h�•��_I <br /> E ail and;or Fax: �� , �.���� r�� � <br /> c � 1�(;J�- <br /> ?I�.�Cc< <-t4�-��55 <br /> P OJECT INFORMA7IQN: Overall projeci description: - � e�C� � �- }�� <br /> ` T pe of Project: Any earth mo�ement m also require <br /> boor(s) ❑ Remodei ❑Fire Damage <br /> MCYVD review&permits: <br /> Re-roof,as hak Minnehaha Creek Watershed Qistrict MCWD <br /> p ❑ Repair ❑Storm Damage � � <br /> Re-roof,cedar 15320 Minnetonka BNd <br /> ❑ Restoration Q 4VaYer Damage Minnetonka,MN 55345 <br /> Re-roaf,other(specify) � Siding ❑ Other;(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.rninnehahacreek.orq � <br /> E titnated Construction Valuation of Praject{excluding Eand) $ <br /> A PLfCAfVT ACKNOWLEDG�MENT: <br /> Agrees to provide all information required or requested by the Buiiding Department; <br /> Certifies that the information supplied is irue and correct to the best of his/Mer knowledge. The applicani recognizes that they are <br /> solely respansible for submitting a complete applicatlon being aware that upon faiiure lo do so, the staff has no alternative but to <br /> reject it until it is complete; <br /> Some or al{ ef the infoRnation that you are asked to provide on this applicatipn is classifred by State iaw as eit�er private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Gonfidential data is information which generally cannot be given to either the pualic or the subject of the data. Our purpose and <br /> iniended use of this irrfotmation is to annually updaie our records and records of other govemmental agencies requined by law. If <br /> ou refuse to su I inFormation,the� lication rna not be issued. <br /> App icant's Signatu . `� Date: (�;—�—c��,�1 <br /> O e�'s Sigha�ture: . Date: <br /> Las[ pdated:January 2016 <br />