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From: 05/�8/20�6 �5:09 #020 P.002/005 � ` , City of Orono Building Permit Application for Maintenance/ Replacement/Remodel—Residential ONLY (i.e. windows, doors, siding, re-roof, etc.—NC? STRF1CTti4�AL EXPANSI�N) �O A, Mail PO Bo�r66 Permit number� —a d f v� Crystal Bay,MN 55323-0066 Date received: S��- � � Street Address: Received by: s � 2750 Keliey Parkway Plan review fee: `�� L prono,MN 55356 qKfSH�� TotalFee: /� �� Main: 952-249-4600 Fax: 952-249-4616 www.ci.oronq.mn.us y� This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please prinf} GENERAL INFORMATION: Job Site Address: 2�$4 St�}oyi..l�.a� ��.p- �2.D�a, N�� Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No If yes,a specra!event permit is required wlth Police Department and City Council approva!60 days prior to the event. ShutUe bus service will be required unless appllcant demonsfrates su�cient on-site parking is available. Non permitted events wil/not be allowed. CONTRACTOR!APPLICANT INFORMATION: Name: l��ks,z".�+t- C on�y�"L�s�fa�1 e oM�,rc2,.C.i� State License# gL 7e� 473 Expiration Date: 3-;1-!� Lead Certification Number: �t1A�"- F�,SZ-851.—2. Expiration Date: y.-�o-Zo (for work on homes that were constructed prlor to 1978 Phone: (celi) (�(2 _ $�S"-- �Lb� (office) "7�3 - 4�1�t - 8?�0 MailingAddress: ��e� ��tpw�T--ri��a-� 5�". ��.t, r� l03 City: r-�.�r�t„E t-'t..tr�.l ZIP: ,�*,S Contact Person: �q.c»,r1 L.��,c,..i Applicant is: Contractor ! Homeowner �c��o�� Email and/or Fax: (��,.� ��5;� ��,ar�-!. c,c� 'j�3 - 4"7q - b6 00 PROPERTY OWNER INFORMATION: Name: ..,sE�'�`t `� f��tz..; ,4-wt�.,.tT Phone(day): `�5 2 - q'7 S -� �30 4 Address: '3�?5 .��cA�S M t�-� E� City: Lc�4 L,�F-k.E. ZIP: 55��--6 Email and/or Fax: �-E,� . /��..1�` e Mo�G,�4�1 Sih+.l�.y . La� PROJECT INFORMATION: Overal! ro'ect descri tion: `� �'�i°�-�� S��r'�L-- a�- w orx.�c Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage MCWb review 8 permits: �Re-roof,as haR Minnehaha Creek Watershed Qisfrict(MCWD) p ❑Repair ❑Storm Damage 15320 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 ❑Re-roof,other(specify) {�Siding ❑Other:(specify) Phone: 952-477-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora Estimated Construction Valaatfon of Project(excluding land) $ h►,y�� , o a 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 confiden#ial. 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 govemmental agencies required by law. If ou refuse to su I th i o tion,the a lication ma not be issued. � ApplicanYs Signature: Date: 5"��`-�� Owner's Signature: Date: Last Updated:January 20t6