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City of Orono '503�� BuildingPermit Application for Maintenance / Renovation pp �3� (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: 4013- 0011,5 Og,0,�0 PO Box 66 Crystal Bay, MN 55323-0066 Date received: 2• Street Address: Received by: Gtiti 2750 Kelley Parkway �• �� Plan review fee �j �agE$x0 Orono, MN 55356 �� ao l3-D D I ( Z/1 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us s, ut, 3 This application form must be completed in full and all required information mu§f be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: �� t ��/� Job Site Address: (� l�J • Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No /f 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 parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: !tiQ3h�l M'Az li Bo(, ,b State License# 8G 3 QD/61 Expiration Date: 3/3/113 Lead Certification Number: ^f4T ZZ�c, -I Expiration Date: (for work on homes that were constructed prior to 1978 Phone: �� ` 935--7z/V? (office) 1411 " 069- (cell) Mailing Address: 5 City: 11,5 ZIP: -5-53L/3 Contact Person: pE1112E_ A54 -6)L__ Applicant is: ontra to / Homeowner (Circle one) Email and/or Fax: x04,4 % PROPERTY OWNER INF RMATION: Name: Phone (day): QRZ_ 5/pc1_z3ob Address: ZWCity: � � ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require gDoor(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re-roof, other(specify) ❑ Siding Other: (specify) Fax: 952-471-0682 gWindow(s) www.minnehahacreek.org Overall Project Description: D)j � Estimated Construction Valuati n of Project(excluding land) $ 3;:�:Etz) 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 information is to annually update our records and records of other governmental agencies required by law. If your se tp supOy the information,the application may not be issued. / Applicant's Signature: 1k,— Date: Last Updated: 08-09-2011