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` City of Orono Building Permit Application for Maintenance I Renovation (windows, doors, siding, re-roof, etc.) �--- Mailing Address: Permit number. 010 1 PO Box 66 Q 0� Crystal Bay, MN 55323-0066 Date received: t a� StreetAddress: Received by: 2750 Kelley Parkway Plan review fee: Orono,MN 55356 - D(' -Z7 -1 Main: 952-249-4600 Fax: 952-249616 www.ci.orono.mn.us Total Fee: 2 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: 10 -92 , Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes 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 paddng is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: r_I moi"" State License# ...3 Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that were consfracted prior to 1978 Phone: - - (office) - f�, (cell) Mailing Address: Clty: --+ZIP: Contact Person: 05-A;WOYL.�7 it , Applicant is: Conor / Homeowner (cftie one) Email and/or Fax: PROPERTY OWNER INFO TION: Name: Phone(day): Address: e- City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: roof, asphalt "'' C]Repair Minnehaha Creek Watershed District(MCWD) ❑Storm Damage 18202 Minnetonka Blvd ❑Re-roof, cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 ❑ s Phone: 952-471-0590 Re-roof, other (specify)pecify) ❑Siding ❑Other.(specify) Fax. 952471-0682 ❑Window(s) www.minnehahaoreek.ora Overall Project Description: Re np Estimated Construction Valuation of Project(excluding_land) $ r OC-0 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 informati to annually update our records and records of other governmental agencies Leguired by law. If you refusein ation,the application may not be issued. Applicants Signature: L Date: 9-93— 2�Ll Last Updated: 08-09-2011