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. �,-30. 2011 3: 24PM Property Claim Solutions No. 6733 P. 1/1 City of Orono Building Permit Application for Maintenance / Renovation windows, doors, siding, re-roof, etc. MaNngAddresa: Permit number: oZ U 1 O l Q� 0 PO Box 66 0 Crystal Bay,MN 55323-0066 Date received: SfreetAddress: Received by: c 2750 Kelley Parkway Plan review fee: Orono,MN 55356 �o ? Main: 852-2494600 Fax: 952-249-416 www.d.orono.mn.us Total Fee: 5®vP, 2j This application form must be completed in full and all required information must be submitted. Incomplete applications will be retumed. (Please pdnq GENERAL INFORMATION: Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes U N6 if M a special event perrrdt Is►equhed wain PoNee Depwbnent and Cly Council approval 60 days prior b Elie event 3hutlk bussemWwx be required unless appUcent demonstrates suAteient on-Me parlor is avedabb. Non-pwm ed events wit not be allowed. CONTRACTOR/AP LICANT INFORMATION: Name: State License# Expiration Date: 3126212, I Lead Certification Number: Expiration Date: (for work on homes Drat were consbacted or to 1878 Phone: (office) Ur7l OU (cell) Mailing Address: City: ZIP;LEUX Contact Person: Applicant is: ntractor d/ Homeowner 0"ons) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: Phone(day): Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Profect Any earth movement may require ❑Door(e) ❑ MCVVD review&permits: Remodel Fire Damage Minnehahe Creek Watershed District(MCWD) ❑Re-roof,asphalt 00pair ( m Damage 16202 Minnetonka Blvd ❑ ,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 Phone: 952-471-0590 roof,other(spa ) ❑Siding ❑Other.(specify) Faic 852.471-0662 — QNB Window(s) www.minnehahacreek.org Overall Project Description: Estimated Constructlon Valuation of Proect(excluding land) S 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 hMer 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 elther private or confidential. Private data is ink madon which generally cannot be given to the public but can be given to the subject of the data. Confldential data is Information generally cannot be given to either the pubic or the subject of the data. Our purpose and intended use of this' is to annually update our records and records of other governmental agendas wired 01 law. If you refuse to information th "Plication may not be issued.