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City of Orono Building Permit Application for Maintenance I Renovation (windows, doors, siding, re-roof, etc.) 1�,, Mailingr. Address: Permit number. 0`r PO Box 66 Crystal Bay,MN 55326 Date'reoeived: Reaeived:by: Street Address: a 2750 Kelley Parkway Plan review fee' Orono.MN 55356 Total Fee: Mem: 962-249-46M Fax 952-2494616 Mww.a anmo.mn,us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) MNERAL INFORMATION: Job Site Address:5 95 Y Ota Will this be a Parade of Homes,Rsmodelers Sh nee or other display Home? yes No WM a special event permit fa regared with FWke Department and CAy Councl approval W days prfw to the event Shuffle bus service wilt be required unAwe appfrcant demons&V1Q-9 sunklent on-afte parldng is avaryable- Non-pemaed events wol not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: ikseNZ� State License# 3 Expiration bate: TWO]3 Lead Cer iScatlon Number. ~�� "�-a S Expiration Date: y j (for warfc on homes that were constructed,qrior.to 1976 office} (cell) Phone: ` Mailing Address: A C •• •• west C hi est ZIP: SS 1 Contact Person: Applicant is: W42MMZW i Homeowner (chvie on.i Email and/or Fax: PROPERTY OWNER INFORMATION: i Name: S f as kLi '�- Phone(day): I on 50 2. Chy_ ZIP: Address: S Email and/or Fax PROJECT INFORMATION' Any earth movement may require Type of Pr'Olect' MCWD review m permits: Door(s) ❑Remodel ❑Fire Damage Mlnnehahe Creek Watershed District(MCWD) ❑Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd 13eephaven,MN 55391 Re-roof,radar ORestwoon ❑Water Damage Phone- 952-471-0590 Fax: 862-471-0682 [3 Re-roof,other(spectry) ❑Siding Q Other(��) vrww_minnehahacreek,2r9 (�Wirxlow(s) ON@ratl Pro eat Desai tion: a D►. .1.. r ` Estimated Construction Valuatio of Project(pxaludin land) $ 7-,5731 APPLICANT ACKNOWLEDGEMENT: Agrees to provide all information requa'ed or requested by the Building Department; Certifies tot the Information supplied is true and oorre t to the beat 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 completeW. 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 gerserally 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 dais. Our purpose and Intended use of this information is to annually update our records and records of other governmental agencies reqwired by law. if a refuse to supdy the h*nnadon the ao& tion►My not be issued. ADolican's Sionature: Date: ��mo )15-