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. City of Orono � �` � �; .��. Building Permit Application for Maintenance / Renovation '�� (windows, doors, siding, re-roof, etc.) � Mailing Address: Permit number: $ �,�,�. PO Box 66 ; .M ;: Crystal Bay, MN 55323-0066 Date received: Sil3 O r Received by: ,� �� , StreetAddress: �,�,� t �� ti 2750 Kelley Parkway Plan review fee: 9kESH��`� 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) F; GENERAL INFORMATION: � Job Site Address: o�(�S �C U/VT� �� Will this be a Parade of Homes, Remodelers Showcase Home or 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 6us servic ill be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ` '� CONTRACTOR I APPLICANT INFORMATION: "'� Name: f�P« Tz�s�rt�� -r.�o� G�ZC�v,� � ,� State License# (,G ��a � Expiration Date: Y_ �- ��j/� �;� Lead Certification Number: Expiration Date: :� (for work on homes that were constructed prior to 1978 `� Phone: �`�,a��—��gU-7 (oifice) (cell) � Mailing Address: f73iC /�C<-/l9`/�/i� �I/� �!C� City: �sq��zz�C ZIP: S��L�L� L� Contact Person: 7J�� -��5.�L Applicant i ontractor /� Homeowner (Circle One) � �---- 4� Email and/or Fax: q S,'�- a5.5- �3! �I a�Fftx� � ��,+��,.6 l�e Z�s-�o�u-�-,��n . c ��" ;, �� PROPERTY OWNER INFORMATION: �:� Name: �ZI�C 1�-�-1-�� r� K";� Phone (day): 7 G 3 � �1/3 - D�G� � Address: ,3Z(,s L�v�l/ l77.� (_ City: G 2 �,�v ZIP: �35 G � Email and/or Fax �"� ::u ,:3 ,� PROJECT INFORMATION: ;� Type of Project: Any earth movement may require °� O ❑ Remodel ❑ Fire Damage MCWD review&permits: `� ❑ Door s ��. �,,,`� Minnehaha Creek Watershed District(MCWD) � �Re-roof, asphalt I'��" ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd '-� ❑ Re-roof, cedar � Deephaven, MN 55391 `�5 ❑ Restoration ❑Water Damage Phone: 952-471-0590 � k� ❑ Re-roof, other(spec�fy) �Siding ❑ Other. (specify) Fax: 952-471-0682 =�a ❑Window(s) www.minnehahacreek.orq £� ,� Overall Project Description: �� Estimated Construction Valuation of Project (excluding land) $ �� 1Q � APPLICANT ACKNOWLEDGEMENT: � • Agrees to provide all information required or requested by the Building Department; `�a • 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 governmental agencies re uired b law. If ou refuse to su I the information,the a lication a not be issued. A IicanYs Si nature: L��' � �' �� ' Pp 9 � Date: � �. yi:: 4; Last Updated: 08-09-2011 �'' .�� . . _.. . _ .. _, __ _ ... . _._� __a�w