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I. City of Orono Building Permit Application for Maintenance I Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: • PermIt number: • CO/ 7-0/11-K VsA 01 PO Box 66 0 v0 Crystal Bay, MN 55323-0066 Date received: "1.3 -17 r Received by: "� , i Street Address: l �, �i 2750 Kelley Parkway Pian review fee: q�z+76.Q$�' Orono, MN 55358 Total Fee: Yir.--� Main: 952-249-4600 Fax: 952-249-4616 SNww.ci,RrRfiQ.tnn.us - This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: w 1_ Job Site Address: 4-0 5 (d* .Irk( ..0(• Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 11 Yes ❑ No If yes,a spacial event permit is required with Police Department and City Council approval 6Q days prior to the event. Shuttle bus Service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: rV-4+-5.1 . 'Q -c<%eYN- State License# -5C 1.2009 83 Expiration Date: 3 J 31 Lead Certification Number: c\.jt-r. al.ag3 --1 Expiration Date: L1 115 (for work on homes that were constructed prior to 1978 Phone: (oE' - a(p4 J L 0 6- far iAn (office) (cell) Mailing Address: t9 a b CQ. l-2.,3 "C" W eSA4- city: s yevt\\C. ZIP: 5S 113 Contact Person: _ Applicant is: ontractor / Homeowner (cordo one) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: 1)-e-rt t?Y G1n01/4-1 Phone(day): -t Address: (_oma -Sq 9 - i a'D (,p City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) CI Remodel 0 Fire Damage Minnehaha MCWD review permits: a Creek Watershed District(MCWD) ❑Re-roof,asphalt 0 Repair 0 Storm Damage 18202 Minnetonka Blvd 1:1 Re-roof,cedar ❑ Restoration Deephaven, MN 55391 ❑Water Damage Phone: 952-471-0590 ❑Re-roof,other(specify) ❑ Siding ❑Other: (specify) Fax: 952-4710682 A Window(s) www.minnehahacreek,orq Overall Project Description: \Acs 0 W'.r\aCit,.. UJI:Vs. ,Q.-:Xi S r-9 OP- ;NQS ) Estimated Construction Valuation of Project(excluding land) $ St Q 0.od 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 class'sfied by State law as ether 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 pubifc 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 agencies required by law. If you refuse to supply the information,the application may not be issued. Applicant's Signature: - • ' ; Date: 1'f\-)0U II-