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Vla r. 29. 2018 3:44PM No. 4487 P. 1 City of Orono Building Permit Application for Maintenance/Replacement I Remodel I esid0rl,Uial'IONLY. (i.e. windows, doors, siding, re-roof, etc.--NO STRUCTURAL EXPANSION) Mailing Address: W Pertnrt number PO Box 66 Crystal Bay,MN 55323-0066 Date,received.. Street Address: Recelvert by ' 2750 Kelley Parkway Planreie'W fsOronoMN 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 INFORMATI �^y/ / / Job Slte Address: 03 V!G- (6.-)„? �a / rel! Will this be a Parade of Homes,Remodelar*Show ase ome or other Display Home? ❑Yes ❑ No If yes,a special event permit is required with Police Department and City Council approval BO days poor to the event, Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed, • CONTRACTOR I APPLICANT INFORMATIO • Name: Cij' (--e.k--- ,rz)S _ Ql State License# r7j •' (P aler Expiration Date: '5( 4 ( D Lead Certification Number: O` ! c — 2 _ Expiration Date: C \ 7 2(1 (for work on homes that wore constructed prior to 1978 cJ C! Phone: (cell) (office) Mailing Address: r C-�. <5 C.—Ir w i City:' /�S ZIP: Contact Person: '0,��` ' • •pplicant is: •.n rac •f / Homeowner (circle One) Al Email and/or Fax: 0 . , al&4A r rr-, c� ) 6 PROPERTY OWNER INFORMATION: rrnn (nr �� ,-�^�,-�•� Name: A0rl lanofil 6I?,1l pct ` Phone(day)! + r Address: — r r 0� �� City: tt' ) 1n) f Z l "ZIP : Email and/or Fax: PROJECT INFORMATION: Overall project description: ._- Type of Protect: Any earth movement may also require ❑Door(s) [i]Remodel ❑Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD)Re-roof,asphalt ❑Repair ❑Storm Damage 15320 Minnetonka Blvd ❑Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka.MN 55345 ❑Re-roof,other(specify) siding Other:(specify) Phone: 952-471-0590. Fax: 952-471-0682 Window(s) www.minnehahacreek.orq Estimated Constructio Valu on of Project(excluding land) $ 309S-1 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 inform tion is annually update our records and records of other governmental agencies required by law. If you refuse to supply(►►��ein f rmati the application may not be issued. Applicant's Signature: LJ Date: 3 9 l� ,a- ,) y." 1 Owner's Signature: Date: Last Updated:January 2016