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Nov, 17. 2011 5:09PM No. 07 P. 1 r City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) O A' MadiPO Box Pemri!number: a e//— 17Jr0 66 e `VO Crystal Bay,MN 55323-0066 Date mceived: //—IS— Street .S—Street Address: Received.by: a' 2750 Kelley Parkway Plan reviewI Orono,MN 55356 -Total Feed Main: 952-2494600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted, Inp9mplete applications will be returned. (Please pdnq j GENERAL INFORIAATION- 3 Job Site Address: f0�, S!US 9 Will this be a Parade of Homm,Remodelem Showcase Home or other Display Home? 0 yes UNO j Nees,a spsdal sventperrnlr/a required with Ponce Department and Cny Council eppravel 60 days pdar to the event. Shuffiebusserftem4fibe i requked unless gpplioant dernariatratas suRldent on�e►te parrdny is available Non parr Wed event,will not be allowed. CONTRACTOR/"APPLI A TINIFQTIO�Nt� r I' - Name: /'!^�ty� owy",r, i State license# Expiration Date: I Lead Certification Number: Expiration Date: (for wale on homes that were consbucted polar to 1878 Phone: ,Sd -&G-/-<Y/ (office) fSa -07,00 -f.2.2-2- (cell) Mailing Address: 3WIL 4 City: 0 zip: Ss Contact Person: Applicant is: Contractor (cimisono) Email and/or Fax: i PROPERTY OWNEINFOIYATION: Name: 'k a( Phone(day): fS.2 -A 00- 9s a 2- Address- slo o City: oy1v" ZIP: XSS3.5 °l --Email and/or Fax PROJECT INFORMATION: Type of Project Any earth movement may require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review A permits: Minnehaha Creek Watershed District(MM) f 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) [J Siding Q Other.(specify) Fax: 952-471-01382 ' ❑Window(s) www.minnehahacreek.cra I Overall Project Description: ?Us-ofba"n Estimated Construction Valuation of Project(excluding land) $ / 7, Oop APPLICANT ACKNOWLEDGEMENT: Agrees to provide all information required or requested by the Building Department; I. • Certifies that the Information supplied is true and correct to the best of his/her knowledge,edge. The applicant reoognlzes that they I are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to reject 4 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 agendes wired by law. If you refuse to the i ation,ft application maX not be issued. Applicant's Signature: Date: P-12.11 Last updated: 05-W2011