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City of Orono ,Building Permit Application for Maintenance / Replacement/ Remodel — Residential ONLY e. vti:ldov.'s, doors .D riciy. re-roof, etc. Ne i ` ue cif:AL .`v,X i- �Q<V Mailing Address: Permit number: '- �! PO Box 66 Crystal Bay, MN 55323-0066 Date received: 0—/2 f 7 Street Address: Received by: S `� 2750 Kelley Parkway Plan review fee: Orono, MN 55356 rkt'sHo�` a. �j,/ Total Fee: I 1�-� ' Main: 952-249-4600 Fax: 952-249-4616 . _ • 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: 2_0/5' UJ3 7? 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 be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: COA-i Z.5 /d Oo,-A-)& Z-,(JC State License# /3(' / 7 r. Z2_6g Expiration Date: Q 3� G Lead Certification Number: 4T--/ ( q 2- - Expiration Date: p z,/ 2 o Z (for work on homes that were constructed prior to 1978 Phone: (cell) 4/Z_ Z71_ 2 4'4 (office) 9 _z- 9 2 - g/4 / Mailing Address: 2_R/2 (.c)(.)Lail/D4 L 4 tJc City: 44./4 ZIP: _575---e-re Z[/ Contact Person: / / 1 C O,Q Applicant is: ontractor / Homeowner (circle one) Email and/or Fax: c� -7te3 4r 11,196 q Mme; (, c©Al PROPERTY OWNER INFORMATION: \l Name: 5'0.E-.IlJ R t M AA) Phone (day): ( (Z._ ° 1e _ S-320 Address: 2-0/6W c13E/e 1-{/w< /2.L2 City: /2 DAlc) ZIP: \_)--:<-3-3?/ Email and/or Fax: PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require ElDoor(s) 0 Remodel 0 Fire Damage MCWD review&permits: Re-roof, asphalt ❑ Repair El Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑Re-roof, cedar 0 Restoration ❑Water Damage Minnetonka, MN 55345 0 Re-roof, other(specify) ❑Siding IDOther: (specify) Phone: 952-471-0590 Fax: 952-471-0682 0 Window(s) ' Estimated Construction Valuation of Project(excluding land) $ /2 , S 06 . 0 0 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 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,thehe/application may not be issued. Applicant's Signature: .u.�.v, ( _79 Date: ( -/Z - Z Di 7 Owner's Signature: Date: Last Updated:January 2016