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NI i NOL)-21-2011 12:56 From: 6785736615 To:9522494616 Page:2'2 City of Oron Building Permit Application for Maintenance / Renovation (windows, doors, siding, re400f, etc.) Mailing Address: Permit number: c)20/1 p ,// �`4/ #°11.:)) CO taI Ba `�_ `i _�� Crystal Bay, MN 55323-0066 Date received:1, Received by: -- i ' Street Address: a ;� : 2750 Kelley Parkway Plan review fee: �'��i� Orono,MN 55356 � . Total Fee: A q,AS Main: 952.249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all requirled information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: {mom ) h S . Job Site Address: >V L. J Will this be a Parade of Homes, Remodelers Showcase Home or other Display;Home? ■ Yes ►:J No If yes,a special event permit is required with Police Department and City Council approval B0 days prior to the event. Shuttle bus s ice will be required unless applicant demonstrates sufficient on-site parking is availabl . Non-permitted events will not be allowed. CONTRACTOR 1 APPLICANT INF MA ION: Name: 54%,..ov. L0 vC•i-. ..o... ` State License# 5 (, Expiration Date: -3/12 Lead Certification Number: tower 7'356- k Expiration Date: ililc (for work on homes that were constructed prior to 1978 Phone: _(ipL 5 I 000 (office) (Cell) city: >rn5�t lk ZIP: Mailing Address: I'Z3 ./ ;vit..- ► v. 15v - Contact Person: ;,,t 4.,.tia Applicant s: Contractor Homeowner (circle one) Email and/or Fax: Jctq • s f non Cors uC hih4 m •Co + PROPERTY OWNERIN ORM IO i Name: -,...1 ewe Avid CI t 11 Phone (day): _ C� Address: 5D t till, L." 5. City: 0trOO ZIP: 55.-- Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits: ❑Door(s) 0 Remodel ❑Fire Damage Minnehaha Creek Watershed District(MCWD) Ill Re-roof,asphalt 0 Repair 124 Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑Re-roof,cedar 0 Restoration D Water Damage Phone: 952-471-0590 o Re-roof, other(specify) ❑Siding ❑Other:(specify) Fax: 952-471-0682 www_minnehehacreek.orq ❑Window(s) Overall Project Description: l.✓ C s h 1 ✓c i0 bA. Estimated Construction Valuation of Project(excluding land) $ I2, 00 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 iis/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 i§ classified by State law as either private or confidential. Private data is information which generally cannot be giv n to the public but can be given to the subject of the data. Confidential data is information which generally cannot be give to either the public or the subject of the data. Our purpose and intended use of this information is to annually update ou records and records of other governmental agencies re.uired b law. If ou refuse to su..1 the information,the application may not be Issued. ..�- Applicant's Signature: _ Date: 11 2lZo �1 f