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`OCT-24-2011 10:24 From: To:9522494616 Pase:2,4 City of Orono Building Permit Application for Maintenance / Renovation windows, doors, siding, re-roof, etc. Mailing Address: Per,mit num Q l�— Og. .�O PO Box 66 Crystal Bay, MN 55323-0066 Bete received! d �. Street Address: Recdlv6d by: 2750 Kelley Parkway Plan review fe li: IL Orono,MN 55356 Main: 952-249.4600 Fax: 952.249-4616 Total Fee` ,�06,� v�ww.ci,orono.mn.us This application form must be completed in full and all required information must be submitted. GENERAL INFORMATION Incomplete applications will be returned. (Please print) Job Site Address: : 'D —TW-)( Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes UNo it yea,a special event permit Is requited with Police Department and City Councll approval 6o days prior to me evegt Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events w;l not be allowed. CONTRACTOR/ PPLICANT INFORMATION: Name: T A)nR Kt A-+ -Se(U i - State License# ec< ({ j' Expiration Date:, Lead Certification Number: n - _38'- J Expiration Date' (e j (for work on homes that were constructed prior to 187a Phone: WRIGHT-AT-HOME BERVICE8 INC (office) (cell) Mailing Address: 01%M MONTICELLO LANE N City: ZIP: Contact Person: p Applicant is: on actor / Homeowner (Circle One) Email and/or Fax: t PROPERTY OWNER INFORMATION: Name: Phone (day); '(0/a -WZ qV U Address: -bo -Tb-n Its City: OwfC*\.Q ZIP•55 j S l0 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 Desphaven,MN 55391 Phone: 952.471-0590 ❑Re-roof,other(specify) ❑Siding ❑ Other: (specify) Fax: 962-471-0682 ❑Window(s) �w.minne 1f+ hahacreek.ora Overall Prdect Descri ion: Estimated Construction Valuation of Pro'e t(excluding land) $ 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�pplicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do sb,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 b a given to the subject of the data. Confidential data is information which generally cannot be given to either the public or t Is 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 supelx the information the application may not be issued. Applicant's Signature: 662,ia Date: /6 411ab�f Last updated: 08-09.2011