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,.:� , � �°` � �"�,� ��' City of Orono � ��.� . � Y • B�;�Iding Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) ;� "�� Mailing Address: _�8�'j � 4►„�,�. PO Box 66 Permit number: ;-� fi / �� � � Crystal Bay, MN 55323-0066 Date received: // � a, � �� , Street Address: Received by: �„ �' �;�= ti 2750 Kelle Parkwa � � Y Y Plan review fee: t9kE xo4"� Orono, MN 55356 �,.� � S Total Fee: ��'" ��j � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ��'X� �� 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: �� G/(�,,,�j� �/o � 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 Po/ice Department and City Council approva/60 days prior to fhe event. Shuttle bus service wil/be ' required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ,.�, ; CONTRACTOR/APPLICANT INFORMATION: Name: �'"t�G(G,l�� _L�pF� State License# a p�� 7 � Expiration Date: p�-3/_ � � �,� Lead Certification Number: Expiration Date: " (for work on homes that were constructed prior to 1978 �/� � ( � � 3 X' Phone: (office) �l� ' �� (cell) : ,� Mailing Address: �p L��j� <�i�.-,,� City:/�l�/L ,�ijD�ZIP: S �6 Contact Person: �,� Applicant is: ntract / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER FORMATION: Name: ��(( ,�JC. (C l Phone (day): ��3 a,�`-� Address: � p�j�!' ,S(� ��,{ �� City: `�� ZIP: Email and/or Fax � PROJECT INFORMATION: {,:' Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: 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 ❑Window(s) www.minnehahacreek.orq Overall Project Description: y'G�' oF� ��oo C c�' .5��l�-�S' � Estimated Construction Valuation of Project(excluding land) $ /� QOC� % � F APPLICANT ACKNOWLEDGEMENT: � � �/G-// �. • 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 governmental agencies re uired b law. If ou refus to su I the ' formation,the a lication ma not be issued. "`' � ApplicanYs Signature: Date: �T-�S- �/ Last Updated: 08-09-2011 ':r3 ,, raz;