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� ` � City of Orono Building Permit Application for Maintenance / Renovafion (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: � G - (i� �.,�,� PO Box 66 ,� Q Crystal Bay, MN 55323-0066 Date received: — — f � �an�"..r Received b I a .� �, s, S tr e e t A d d r e s s: Y� `�� ` r�a�' ti � Gti 2750 Kelley Parkway Plan review fee: t9'kE5H�4� 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. Incomptete applications will be returned. (Please print) GENERAL INFORMATION: ��, Job Site Address: �� `� - �� Will this be a Parade of Homes, Remodelers S owcase ome or other Display Home? ❑ Yes No If yes,a specia!event permif rs required with Police Department and City Council approval 60 days prior to the evenf. Shuttle bus s rvice will be required unless applicant demonstrates sufficienf on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: •�',� � r r' ✓l� • State License# �j��r'] Expiration Date: 3/3� 13 Lead Certification Number: ��_ .�/�,��yG _ , Expiration Date: 5��_ (for work on homes that were constructed prior to 1978 Phone: _ �- ��j'�/�--- (office) cell � ) Mailing Address: b - � � Cit : �;i�ZIP: 5 � Contact Person: �� Y �� ,�r-c Applicant is: Contrac or Homeowner (Circle One) Email and/or Fax: ��3 _ i�� _��'j� PROPERTY OWNER INFORMATION: • Name: /�Uz.d/S L.tiG'�i c:, I-C��d U..�- � Phone (day): �� .. � Address �I�1� (o�— ,t' /'� City: ��C;yLL ZIP: �j_j5'�C�� Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel MCWD review&permits: ❑ 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 ' ❑ Re-roof, other s eci Phone: 952-471-0590 ( p fy) ❑ Siding ❑ Other: (specify} Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Overall Project Description: - ��,�- � L �. -�G(� �' ��r Estimated Construction Valuation of Project(exc ing land) $ �� j��, 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 sotely responsible for submitfing a complete appfication 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 ctassified by State law as either private or cor:idential. Private data is information which generally cannot be given to the public but can be given to the subject of the da;G. 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 informat' n is to annually update our records and records of other governmental agencies re uired b law. If ou refuse to su t info ation,xh a lication ma not be issued. ApplicanYs Signature: � Date: ''� �j/��jl � Last Updated: 08-09-2011 ;,