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Mar. 2. 2017 2: 53PMNo. 3386 P. 1/2 * Pte. City of Orono Building Permit Application for Maintenance I Replacement/ Remodel-itiodoitioNts (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) Mailing Address: ?Oth tg .iy Sax 66 d Crystal Bay, MN 55323-0066 eagAgeNedi . � e1v.11 �lG Street Address: 2750 Kelley Parkway lahrt,11 4%,§' k8i'l(IJ Orono,MN 55356oTst0..11:0? x = • Mnai : 952-249-4600 Fax: 952-249-4616 www.cl,orano.mn, This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERALINFORMATION: Job Site Address: ^, t-1 (A) / C0-00Y\ i0/ Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ( No If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event, Shuttle bus service will he required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: 5 A "r'e_Ar- To gat State License# + - Expiration Date: .6 Mann Lead Certification Num>`1 •\ , 1 _ Expiration Date. _ (for work on homes that were c.n.tructod prior to 19 ; 6 �] `_ `� Phone: (cell) (office) 7 ) / // O ` Mailing Address: J City. _5K ) AAS ZIP' SSW Contact Person: �i L/�,. • Applicant is: -ontracto' I Homeowner (circle on" Email and/or Fax: , �a.Y • /l V)------. PROPERTY OWNER INFORM•TION: OP Name: - _ el Phone(day)' _ - r Address: H �� /, . . .gym ..0 *j_ City: r YZi ZIP: S Email and/or Fax: PROJECT INFORMATION: Overall project description:_ Type of Project: Any earth movement may also require MCWD review&permits: ❑Door(s) 0 Remodel ❑Fire Damage Minnehaha Creek Watershed District(MOND) ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage 15320 Minnetonka Blvd ❑Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka,MN 55345 Phone: 952-471-0590 El Re-roof, other(specily) LiSiding ❑Other: (specify) Fax: 952-471-0682 • dow(s) _ yfyrw.mihnehahacreek.gfq Estimated Construction aluation of Project(excluding land) $ `(,aD APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Departme , • 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:lhe 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 ou refuse to su'.1 the Information the .'ilicatlon ma not be issued. Js / Applicant's Signature: A —71:-; i 1 F . rt' i Date. Owner's Signature: _ Date: Last Updated:January 2016