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s City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address' Permit number: U PO Box 66 Q Q�Q Crystal Bay,MN 55323-0066 Date received: Received by: Street Address: — F 2750 Kelley Parkway Plan review fee' Orono, MN 55356 Tota{l=ee: Main: 852-249-4600 Fax: 952-2494616 www.ci. no.m 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: --i� Job Site Address: a C) Tow r` Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No City l � el � the event bus service will tr6 f yes,a special event permit ill not be alllowed. required unless emOntessu cienr on-sit8 png is available. events w CONTRACTOR I APPLICANT INFORMATION: Name: State License# "$G1-609 83--, Expiration Date: 3 f 31 Lead Certification Number: t,j��1 a 3 — 1 Expiration Date: �{ (for work on homes that were constructed prior to 1978 (cell) Phone: cosi— a 40° 4 "(office) Mailing Address: l�o� C �• '• We City:-Jcyr,t ee ZIP: SS 3 Contact Person: Applicant is: VContractor / Homeowner (circle anel Email and/or Fax: PROPERTY OWNER INFORMATION: Name: o�S �r'ti Ski Phone (day): ZIP: Address: City: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits: Doors) ❑ Remodel 0Fire Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑ Re roof,asphalt © Repair []Storm Damage Deephaven,MN 55391 [] Re-roof,cedar ❑ Restoration ❑Water Damage Phone: 952-471-0590 Sidin ©Other: (specify) Fax: 952-471-0682 Q Re-roof,other(specify) ❑ 9 ww ._minnuhahacre org �Window(s) Overall Project Description: ` t Estimated Construction valuation of Project(excluding land) $52110 APPLICANT ACKNOWLEDGEMENT: •EAs to provide all information required or requested by the Building Department: • ies that the Information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they olely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative reject it until it Is complete; or ail of the information that you are asked to provide on this application is classified by State law as either private or dentai. Private data is information which generally cannot be given to the public but can be given to the subject of the Confidential data is information which generally cannot be given to either the public or the subject of the data. our ose and intended use of this information is to annually update our records and records of other governmental agencies red b law. If ou refuse supply the information,thea !ication ma not be issued- Date: ac; ��s Aonlicant's Sianature: