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Ju1. 23. 201210: 21AM No- 9325 P. 1 City of Orono Building Permit Application for Maintenance I Renovation windows, doors, siding, re-roof, etc.) Mailing Address: Permit�number. Ogir 0.�0 PO Box 66 Crystal Bay, MN 65323-0066 Date.received: 7 a Sheet Address: Received by: off' 2750 Kelley Parkway Plan review —�� Orono,MN 55356 Total Fee':::' Main: 952-2494600 Fax: 952-249.4616 www.ci.orono.mn.U �.. O This application fvrrn must be completed in full and all required information must be submitted. GENERAL INFORMATION: Incomplete applications will be returned. (Please print) Job Site Address: ZJ L T t, Will this be a Parade of Homes,Remodelers Showcase Home or other isplay Home? El Yes M No If yes,a Veda/event pen»if is required with Polios Department and City Councd approve!60 days prior to the event, Shuttle bus service wr71 be required unless applicant demonstrates suftent on-site perking Is available. Nonpeimitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: ,� 5- State State License# IDC a 3�� Expiration Date: 3 Lead Certification Number: PK _ f a c Expiration Date: (for work on homes OW wane lconstructed prior to 19 Phone: QS Q -ZkC7rl-(s. SCI (ice) (cell) Mailing Address: 'Q S, I 1C Cel S r� es( t city: 1,I=O K; ,a ZIP, S5_'3 4f l Contact Person: Q& ztQ Applicant is: Contractor / Homeowner (arms Ons) Email and/or Fax: Oi Q-A:]—( k' � �3 PROPERTY OWNER INFORMATION: Name: S -f Phone(day): U 1 a - 3 _ 7 k'o Address: I I ke u w C, A City: ZIP: Email and/or Fax L o PROJECT INFORMATION: Type of Project Any earth movement may require ❑ Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: [I Re-roof,asphalt Minnehahs Creek Watershed District(MCWD) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 [I Re-roof,other(s Phone: 952-471-0590 (specify) ❑Siding ❑Other.(specify) Fax: 952.471.0682 findow(s) www.minnghahacreek.oro Overall Pro ect Description: Estimated Construction Valuation of Project(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 or 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 information is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the information,the application may not be issued. Applicant's Signature: �c ,g, C Date: c] A._-o,l/-i— _ Last updated: 08.09-2011