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Mar, 10. 2015 12: 17PM No. 0177 P. 2/2 146 City of Orono Building Permit Application for Maintenance / Replacement / Remodel (I.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL. EXPANSION) Mal!!ng Address: PO Box 66 Permit number:. 2.06 Qfl Crystal Bay,MN 55323.0066 Date received. [(}1 5 Street Address: Received by. p. y� �'� 2750 Kelley Parkway Plan review fee: Orono,MN 5535(3 1tkssttoat �l0 �`7 Main: 952-249.4600 Fex: 952-289-4816 www.ci. Total Fee,ono.mn.us ,r This application form must be completed in full and all required information must be submitted. GENERAL. INFORMATION: Incomplete applications will be returned, (Please print) �a Job Site Address: a (� �- r a Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes Jallo If yes,a special event permit is required with Poke Department and City Council approval so days prior to the event. Shuttle bus service will be required unless applicant demonstrates sutgclent on-sile paddng is available. Non-pemtified events will not be allowed. CONTRACTOR/APPLICANT INFOR ATION: Name: `Z)4C �ongiruc State License a Z Expiration Date: 3 Lead Certification Number: NA-T Expiration Date: S-. /r' Zo (for work on homes that were constructed prior to 1978 Phone: (cell) (office) Mailing Address: 363 tin, ba LN A y, Cit . y,) !P ZIP: yn N Contact Person: Applicant Is: kQontractorHomeowner (Circle 0ne) Small and/or l=ax: 1b r b PROPERTY OWNER INFORMATION: Name; T,r ; Phone(day): q S'Ca - y Address: 03,80q�1tr owrl c� City: 1,gLe ZIP:<53 sb Email and/or Fax: ,t.n O PROJE=CT INFORMATION: Overall project descry tion: ra\ 0 �NoUoq ,l^-k-t Ao�s_ Type of Project: Any earth n1ovement may 97so require Lar, ❑ Door(s) ❑Remodel MCWD review&permits: ❑Fire barrage p XRe-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) El Re-roof,cedar ❑Restoration 18202 Minnetonka Blvd ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952471-0590 ❑ 82 Window(s) www.Wlnnehahacreek.org Estimated Construction Valuation of Project(excluding land) $�+ / ,ao 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 govemmental agencies required by law. If you refuse to supply the Information t �Ilcon may not be issued. Applicant's Signature Date: / Owner's Signature: Date: Last Updated:January 2015