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Octr" 1'`1'1 1 �08: 57a Enhanced Home Improvement 651 -528-6361 p. 1 City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: /�-U/ og,O,jOO Cr Box t36 Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: 2750 Kelley Parkway Plan review fee: Orono, MN 55356 _ Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www_ci.orono.mn.us If This application form must be completed in full and all required information must be submitted. o O Incomplete applications will be nAurned. (Please print) GENERAL INFORMATION: 4� �N iivf�w Job Site Address: ,Y A Will this be a Parade of Homes, Remodelers Showcase Home or other Display Homed Yes No If yes,a special event permit is required with Police Department and City Council approval W 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 I llowed_CONTRACTORI APPLICANT INFORMATION: Name: E1411HWC err ffDM�' div, Ro VEMt•t rs .�^+G State License# 79 L 1,3 0 ¢ Expiration Date: 3- S J^ 20712- Lead 712Lead Certification Number: Expiration Date: /f- (for work on horses Brat were constructed prior to 1878 Phone: (057- 45 7.- 9,0.0/ (office) ZP12 - S79 9- .5-&5�9_ (cell) Mailing Address: 110flf W/rBY City: 45A ZIP= S/2Z Contact Person: yfEPHE/tf 1 OtiS Applicant is: ontrac or / Homeowner (erra.om) Email and/or Fax: 5ZIY - PROPERTY OWNER INFORMATION: Name: /Y1 j I<E f .0wA.44-16-e L)D M Phone(day): Jra - 4 71--- Address: p,r.ff#qWA b City: Rb"O zip: 5S3 S46 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) V(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: 9521471-0682 ❑Window(s) www-minnehahacreek.oro Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ G►Od . '00 APPLICANT ACKNOWLEDGEMENT: V15a _d* &F S-13 • 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 nerally cannot be given to the public but can be given to the subject of the data. Confidential data is inform 'on hic nerally can be given to either the public or the subject of the data. Our purpose and intended use of thi i ati s to nuel date our records and records of other governmental agencies required b law. If you refuse to th rm ' n l:cation may not be issued. Applicant's Signature: Date: Last Updated: 08-09-2011