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City of Orono Building Permit Application for Maintenance 1 Replacement/ Remodel Reslc� ntll`bIVL (i.e. windows, doors, siding, re-roof, etc.- NO STRUCTURAL EXPANSION) .` Mailing Address_ Permit number: 000 PO Box 66 Crystal Bay, MN 55323-0066 Date received: 7 Street Address_ Received by: 2750 Kelley Parkway Plan review fee: Orono, MN 55356 Kss�° Total Fee: 1 y� Main: 952-249-4600 Fax: 952-249-4616 www.ci.arono_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, INFORMATION: Job Site Address: 22 To►1C0L Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Lj Yes No If yes,a special event permit is required with Police Department and City Council approval 60 days prior 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/APPLICANT INFORMATAON: Name: e:my5S %A/,IL K&W G tky State License 4 --1 BG L,T-7,? ' — Expiration Date; zwl Lead Certification Number: N/+T 123125-Z Expiration Date: Z Z (for work on homes that were constructed prior to 9978 Phone: (cell) (office) 00 ,4544-2'775_ -2'775_ Mailing Address: NAW- City; ZIP: Contact Person: Applicant is: ontract ! Homeowner (circle one) Email and/or Fax: ( K �SW,�td�oWduvr Cdt+�c PROPERTY OWNER INFORk4ATION: Name: f-e Iu,,c�Q Phone(daffy)' ! Address 27-S "7`aKk City: prwo ZIP: 5753S- Email and/or Fax: f'`'lit,i'•co� PROJECT INFORMATION: Overall project description: S 51 �'�� ? �11/a�C��►` w�G�l . Type of Project; Any earth movement may also require ❑ Door(s) ❑Remodel ❑ Fire Damage MCWD review&permits: ❑ Re-roof,asphalt ❑Repair ] Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑ Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 ❑ Re-roof,other(specify) ❑Siding ZOther:(specify) Phone: 952-471-0590 Fax: 952.471-0682 ❑Window(s) q�� www.minnehahaceek,orq Estimated Construction Valuation of Project(excluding land) $ 3 Z06,DD 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 information Is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the information the app lic may not be issued. Applicant's Signature: - Date: Tl , 7 Owner's Signature: Date. Last Updated:January 2016