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01a) ...,()));City of Orono Building Permit Application for Maintenance 1 Renovation (windows, doors, sidin , re-roof, etc.) Melting Address: Permit•riumbefi' D/S- Q./..3 S.� CerblVe.iP0Box88 . . •Crystal Bay,MN 55323-00®0 Date'recelied, 70-04D —!S,l, �. Sire®t Address:• Reoeived by'1, 4" 2750 Kelley Parkway plan review free:, ‹urae a� Crone, MN 55358 Totdl'Fee. ..,9 Main; 952-249-4640 Fax: ®52-249-4816 www.ci.Qronc,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: i _ Job Site Address: ,, , , /CD , QL ' .f i, 5344 Will this be a Parade of omes, Remodelera Showcase H•me or other ■splay Home? it Yes P o /firm,a special event pennit Is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus 3-' ea will be required unless applloant demonstrates sufficient on-aite parking Is available. Non-permitted events will not be allowed. CONTRACTOR 1 APPLICANT INFORMATION: Name: VjW.,7 ' r.5AA4 State License# eey .- gy7 Expiration Date: 3 3/ /E, Lead Certification Number: a M Expiration Date: b i a La (for work en homes that were construe d prior to 1978 Phone: - ,t - .,. o-„c o/ (office) (cell) Mailing Address: 012 // --1 a ? dug A", 3-f fp �•.Cl : 4tL ZIP; , ,�-rte Contact Person: Applicant is: •ntrector. / Homeowner (CiroleOne4- Email and/or Fax; L, / . PROPERTY OWNER INFORMATION: Name: "�� (1d/JN Phone(day): Address: l i f id/44AAA tS t I L lCity: r) f__o ZIP:55 Email and/or Fax Ap,c— PROJECT INFORMATION: Type of Project: Any earth movement may require ❑Door(®) 0 Remodel ❑ Fire Damage MCW&review S permits: ❑Re roof,asphalt . Minnehaha Creek Watershed District(MCWD) p ❑Repair 0 Storm Damage 18202 Minnetonka Blvd CI Re-roof, cedar 0Restoration 0 Water Damage Deephaven, MN 55391 Phone: 952.471-0590 ❑Re-roof,other(specify) ❑Siding 0 Other; (specify) Fax: 952-471-0682 _ AWindow(s) www.mi nnehahaoreek.oro Overall Project Description: ' dLc..1 . / 3 U•--4 -y 1✓ IA. 4 ,y1,,_ c, 'P- '- I Estimated Construction Valuatio of P • -ct(excluding land) $ / 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 sup ly the Information,the application may not be Issued, Applicant's Signature: ' Date: 0-t/` —IS Last Updated 08-09-2011 1 'd Xd3 13CH3SU1 dH Wd90 :e 9102 01 *400