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Sep 29 11 01 : 16p hiemela Construction, Inc 763-428-9020 p. 2 � �� • � � �G � � � � �� City of Orono / Building Permit Application for Maintenance / Renov tion (windows, doors, siding, re-roof, etc.) �O A� MailiPO Box 66� Permit number: �//—dl/ � �w0 Crystal Bay, MN 55323-0066 Date received: / � � Street Address: Received by: � 2750 Kelley Pa�cway Plan review f� �Ho�� Orono,MN 55356 Total Fee. a��, �� Main: 952-249-4600 Fax: 952-249-4816 www.ci.orono.mn.us This application foRn must be completed in full and all required information must be submitted. Incomplete applications will be returned. (PleaSe print) GENERAL INFORMATION: ' �/jO �ar�e I/�1� i� aZy �j/V '�5�� Job 5ite Address: 7 Will this be a Parade of Homes, Remodelers 3howcase Home or other Disptay Home? Yes No K yea,a special event permft is iequired with Police Deperfinent and City Counci!approval 60 days prior ro the evenf. Shutlle bus serv ce will be required uMess applicant demonstretes sulficient on-slte parktng Is evaileb/e. Non-permitted events wllf rrot be allowed, CONTRACTOR/APPLICANT INFORMATtO : Name: �r e�M�P�� CO'�l i�C � h C , State License# a ac��a�4 Expiration Date: 3 3/ ��1 Lead Certification Number: Expiration Date: (for work on home that w co at►wcfed prfor 1978 Phone: 7�a � �-�/yg� office) 7�-3 .��l�"$.�QS (celq Mailing Address; �p 00 a% ✓.&.h � 04< City: 4� , ZIP: ' �]L Contact Person: � � ,'e p� q Applicant is; ontract r / Homeowner (Cfrole One) Email and/or Fax: b Q �� ;p��fi, !�y/S C "0/7. Cc� PROPERTY OWNER I F MA 10 : Name: ,� g'/'/'�S'c�/') Phone(day): � - �l� � Address: _SQ fn e �S ,�o� S/ City: ZIP: Email and/or Fax ' � - PROJECT INFORMATION: Type of Ptoject: Any earth movement may require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review 8�permits: Minnehaha Creek Watershed District(MCWD) Q�Re-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd / ' ❑Re-roof,cedar ❑Restoraqon ❑Water Damage Desphaven, MN 55391 Phone: 952-471-0590 ❑Re-roof,othe�(speciiy) ❑Siding ❑Other:(specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek oro Overall Project Description: rp� ��P Q t/se. — q S 4' ;�I ,�' Estimated Construction Valuation of Proj ct(exctuding land) $ 1 r, 44'Q,a0 APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is hue 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 applicafion is classified by State law as either private or confidential. Private data is information which generall cannot be given to the public but can be given to the subject of the data. Confidential data is information which nera �annot be given to either the public or the subjoct of the data. our purpose and intended use of this i rm o s to�nually update our records and records of other governmental agencies r uired b law. IF ou refuse to s I rmati n,the a lication ma not be issued. ' a9 � / Applicant's Signature: Date: