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11/09/Z012 9:49 AM FAX 16125736615 SIMON CONSTRUCTION 0001/0001 City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) O \ Ma!!!�Box 66 Address: Permit number: O/ $(46 " '1 Crystal Bay.MN 55323-0066 Date received: //-q 2- , , - Received by. Street Address: '7� 4 ,its/ 2750 Kelley Parkway Plan review fee: v^mr� /� Orono,MN 55356 ,0 ko$ Total Fee: l Tr -r- — Main: 952-249-4600 Fax: 952-249-4616 www,ci.Q OJ19,mn.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: Job Site Address: X S-0 k q,lt $i 4. &NU, . It4 J Will this be a Parade of Homes,Remodoters Showcase Home or other Display Home? Q Yes i'No ! if yes,a special event permit is required with Police Department and City Council approval 50 days prior to the event Shuttle bus service will be required unless applicant demonstrates sufficient on-site parldng la available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: S State License# 13c-515(056 Expiration Date: 2/P( Lead Certification Number: Expiration Date: (for Ivor*on homes that ware constructed prior to 1978 Phone: (0g6l boo (office) (cell) Mailing Address: (23 6(o Ikkaa" fLicL t e,1vrA City: ,r 4 Lg. ZIP: 33 Contact Person: Applicant is: •66- ctg. / Homeowner (ctrl.on.) Email and/or Fax: W.P S►vim,✓►Cori si✓dc-+Loo . c. w. PROPERTY OWNER INFORMATION: Name: M. c.1its 14.3A-Vv-‘A‘• •(;1/4. Phone(day): qS2. 1.104_ ip 1[(e Address: f 5O LA. City. 004,01,0 ZIP: SS 3q i Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require [] Door(s) 0 Remodel 0 Fire Damage MCWD rovlew 8 permits: Minnehaha Creek Watershed Dlabict(MCWD) ❑Re-roof,asphalt 0 Repair Storni Damage 18202 Minnetonka Blvd ❑Re-roof,cedar 24estoratiorl ❑Water,Damage Deephaven,MN 55391 Phone: 952-471-0590 ( "Re-roof,other(specify) ❑Siding Q Other:(specify) Fax: 952-471-0682 fu...k Teo ❑Wlndow(s) www.rninnehehacreek.org Overall Project Description: ia.a-rx j . S `f 'rr �p r o,,,, - Estimated Construction Valuation of ProJecti uding land) $ �, 15%. 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 end Intended use of this Information Is to annually update our records and records of other governmental agencies required by law. If you refuse to su ply_the Information the application may not be issued. Applicant's Signature: � Date: �� la/ Last Updated: 08-09-2011