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�- City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, ptc.) <br /> Mailing ddBox 66 'Permit number: <br /> Crystal Bay,MN 55323-0066 Date recelved: <br /> StreetAddrew: Received by: <br /> 2750 Kelley Parkway plan review fee; <br /> r• � Orono,MN 55356 <br /> Total Fee: <br /> Main: 952-249-4WO Fa)c 952-249-4616 www.d.orono.mmus <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 5 WoLy -. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ❑ No <br /> gym,a spoebi event pem/t is required With Police Department and City Counp7 approval 60 days prior to tine event. Shuttle bub sen4o9 will be <br /> required unless applicant demonstrates sufficient on-site perlang is avalable. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 1Cr�tivao.\ 'tel �A �CSe�N <br /> State License# I tC-\309 9'3 Expiration Date: '1501,31 <br /> Lead Certification Number: �j ^r r oZ'�.oZ$3 1 Expiration Date: 4116 <br /> (tbr work on homes that www constructed priar to 1978 <br /> Phone; lot 1- a(e�} q0 gl-%N An (ice) (cell) <br /> Mailing Address: kq alt CO. -12,rj Wec ZIP:_5S llr3 - <br /> Contact Person: Applicant is: ntra / Homeowner (circie one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: A.h t1 Wo- <br /> Phone <br /> o-Phone(day): q5 2 ..41-3 -(0$1 PL <br /> Address; City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Protect: Any earth movement may require <br /> MCWD review$permits; <br /> ❑Door(s) ❑Remodel ❑Fire Ramage Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ❑ Repair ❑Storm Damage 18202:Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other(specify) l=ax: 852471-0682 <br /> Window(s) des www.minnehahacreek.orc <br /> Overall Project Description- (A-3);n 4j)c;S 'r!5 OP-e-�192 <br /> Estimated Construction Valuation of Project(excluding land) (a, t{a(p <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all Information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to da so,the staff has no aitemative <br /> but to reject it until it is complete; <br /> • Some or all of the Information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is Information which generally cannot ba.given to the public but can be given to the subject of the <br /> data. Confidential data Is Wormaation which generally cannot be given to either'the public or the subject of the data. Our <br /> purpose and Intended use of this information is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse t(oo supply <br /> ,the information.thea application may not be issued. <br /> Aoolicant's Sianature: � Date: �✓ ���� <br />