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� �' City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Addr�ss: Permit number.�� —� 7�J O�0�.O PO Box 66 Crystal Bay, MN 55323-0066 Date received: �, Street Address: Received by: �, Gti�' 2750 Kelley Parkway Plan review fee . �•��Ho�.� Orono,MN 55356 2 � 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 applicatfons will be returned. (P/ease print) GENERAL INFORMATION: ` I {� Job Site Address: o�Cv��5 Si �vcr- VI�y I�r,J� (�ro�,o Nl�7 S s �5 (o Will this be a Parade of Homes, Remodelers Showcase Home or other Dlsplay Home? Yes No ff y�es,a specia/event permit is required wiM Police Department and City Council approva160 days prior to the event. Shuttle bus servioe will be required unless applicant demonstrates sufiicient on-site parking is available. Non-pe�mitted events wil/not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: o State License# a a�,Q 2 4 `�1� Expiration Date: 3 � Lead Certification Number: Expiration Date: (f�or w�ork on homes that were constructed prlor to 1978 Phone: 952- 393� 5 3�`j (office) (ceu) Mailing Address: p , + ��, City: ZIP: Contact Person: �� Applicant is: Contractor / Homeowner �ci►�i.o�.� Email and/or Fax: - rCu a' o� � "� PROPERTY OWNER INFORMATION: Name: pek-c.- 11c�n o�e�be4C� Phone(day): (o/Z— �j p- y q�,;�� Address: Z� �S S'�l ve,- 1� i"Q� E7�,'v t- C��Y� o ro r.o ziP: 5 S 3.�.6 Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ,�Door(s} ❑Remodel ❑Fire Damage MCWD review 8�permits: Minnehaha Creek Watershed District(MCWD) ❑Re-roof,asphalt ❑Repai� ❑Stortn Damage 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage �Phaven,MN 55391 Phone: 952�471-0590 ❑Re-roof,other(speciry) ❑Siding ❑Other.(specify) Fax: 952-471-0682 ❑Window(s) �w.minnehahacreek.orq Overall Project Description; ��-4;o Sl t cl e� t`7 0�: 12.e,o�.c e,w.e�t '� Estimated Construction Valuation of Pro)ect(excluding land) i� 5 00.c U 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 altemative but to r�eject it until it is complete; • Some or all of the information that you are asked to provide on this application is Gassified 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 subjed 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 recorcJs of other govemmental agencies re uired b law. If ou refuse to su I the informatio the a lication ma not be issued. ApplicanYs Signature: ��^-ti-- Date: J�ry .3�. ��Z— Last Updated: OS-09-2011