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ooNd0 ,0/2017/THU 04:32 PM Elder Jones Building FAX No, 952 854 4909 P, 002/002 City of Orono Building Permit Application for Maintenance / Replacement/ Remodel -Residential ONLY (i.e.windows, doors, siding, re-roof, etc.-NO STRUCTURAL EXPANSION) A, Mailing Address: Permit number: l PO Box 66 Crystal Bay,MN 55323-0066 Date received: — -17 Street Address: 0 I I' Received by: ' � c• 2750 Kelle y Parkwa /� Plan review fee: sHo�``` Orono,MN 55356 1 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. GENERAL INFORMATION: Incomplete applications will be returned. (Please print) Job Site Address: -3 " Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No If yes,a specfal event permit Is required with Police Repartment and City Council approval 80 days prior to the event. Shuffle bus service will be required unless applicant demonstrates sufficient on-aft parking Is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: State License# Expiration Date: Lead Certification Number: /.57/782- _ Expiration Date: (for work Pella Northland ' Phone: 15300 25th Ave N Ste.100 (office) Mailing Add Plymouth MN 55447 City: ZIP: Contact Pei 763-745-1400 Applicant is: Contracto Homeowner (circle on•) Email and/c BC645090 expires 3/31/19 �'�� (P&-1d k2r'gi22K. C8W PROPERTY OWNER INFORMON: Name: ZAA Phone(day): d 1.2 70 Address: City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall project descri ions 41 Type of Project: Anf earth movement may also requir Vift [9-Door(s��) ❑Remodel ❑Fire Damage MCWD review&permits: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) ElRe roof,cedar 15320 Minnetonka Blvd ❑Restoration ❑Water Damage Minnetonka,MN 55345 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehoh=eek.org Estimated Construction Valuation of Project(excluding land) $ 27. 61D 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 informs' n which generally cannot be given to either the public or the subject of the data. Our purpose and Intended use of this infor tion is to annually update our records and records of other governmental agencies required by law. If you refuse to su 1 t information the application may not be issued. Applicant's Signatur Date: /,� —l/-7 Owner's Signature: Date: Last Updated:January 2016