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City of Orono Building Permit Application for Maintenance / Renovation (windows, d6ors, siding, re-roof, etc.) Mailing Address: Permit number: – Q�Q PO Sox 66 12 Crystal Day, MN 55323-0066 Date received: a, Suet Address:: Received by: 2750 Kelley Parkway Plan review fee: Orono, MN 55356 Q Total Fee: � 0 3 .�J D n+a.:.0 Main: 952-2.49-4600 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) -5o'6G r '� �( w� r�� Job Site Address: J V�J Will this be a parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No W yes,a special event permit is required with Police oepariment and City Council approval 60 days prior to the event Shuttle bus service will be required unless applicant demonstrates suti9clent on-alta parking is available. Nonperrnitted events"I not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: ?Vpt \ A tr State.License# '$G1'30el$"3 Expiration Date: 3 31 Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: Co51– 4,0��- �tyAr` (office) (cell) Mailing Address: 19 a0 C 1� " Wes+ City:'�a.tvtlle ZIP: 46511-2 Contact Person: Applicant is: LContraffox / Homeowner (ciraeone) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: in,T-, , Ge.i Vo,f Phone(day): 5 a. 'Z2-0—RU Address: [5 j City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require D Door(s) ❑ Remodel ❑Fire Damage MCWD review&permits: Mlnnehaha Creek Watershed District(MCWD) ❑ Re-roof,asphalt (] Repair ❑Storm Damage 16202 Minnetonka Blvd ❑Re-roof,cedar ElRestoration ElWater Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Fax: 952-471-0662 Window(s) www.minnehah%cWsk ora Overall Project Description: C a Y\ LAn; �t A61 Estimated Construction Valuatlon of Project excluding land) $ q QOO 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 the application may not be issued. ADolicanfs 5ionature: G'� Date: 17 �� ��13