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q '�"� , City of Orono .. �, . Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) ' Mailing Address: Permit number: - 0�.,D,j�.O PO Box 66 $ Crystal Bay, MN 55323-0066 Date received: i � t' a � s� �, Street Address: Received by: � �;� �'� � ; a'� �ti 2750 Kelley Parkway Plan review fee: -> L9kESH0�� Orono, MN 55356 :+' 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: '�`j�(2 S I1 pr�\� - �� ,Uq U�,��E � � Will this be a Parade of Homes, Remodelers Showcase Home o other Display Home? ❑ Yes �No If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus se ce will be required unless applicanf demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ,v:; CONTRACTOR/APPLICANT INFORMATION: � Name: F V�-\�.s:� C.�-z.; p� R;:1s�-s L.-.{._ ';� State License# �L y-��(� Expiration Date: �M��e9� i `-( Lead Certification Number: Expiration Date: (for work on homes that were consfructed prior to 1978 Phone: f� '��- ��1 — 7��l�"7 (office) 6 i�-_ �,d, _�,7� k (cell) Mailing Address d�cj ��E„� � City: ��,v,._.s, ZIP: � >>'3L,`f ,ki Contact Person: �y�.� ��-Z� Applicant is: Contrac � / Homeowner (Circle One) y� £ Email and/or Fax: \�rti �U c'_Uerl�s��'r�-��s�-s � �o'"� �' � PROPERTY OWNER INFORMATION: �+ Name: __�� d�oov�-�cpv�s�'. � � Phone (day): (�� _ 9�� __ � a.3 ,•: Address: (o/� �� ,� �� ,,U. City: �e�� ZIP: 5�.�3�� .� Email and/or Fax �� PROJECT INFORMATION: Type of Project: Any earth movement may require �a ❑ Door(s) ❑ Remodel MCWD review&permits: k`� ❑ Fire Damage �� Minnehaha Creek Watershed District(MCWD) ��Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd � ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ;;� Phone: 952-471-0590 :,� ❑ Re-roof, other(specify) ❑ Siding � Other: (specify) Fax: 952-471-0682 '*' www.minnehahacreek.orp �� ❑Window(s) /�1.��'� 5�,�,�s � Y�;c,, � Overall Pro'ect Descri tion: � " � � p '� \`�z,Y �.��.�� s `c�cc�� Estimated Construction Valuation of Project(excluding land) $ S g:� `�'— � 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 govemmental agencies `� re uired b law. If ou refuse to su I the information,the a lication ma not be issued. � Applicant's Signature: \-1� �� : Date: 3 � �, y � ::`r Last Updated: 08-09-2011 =-: ,