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it City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structur I expansion. Only windows, doors, siding, re-roof, etc.) * �� Mailing Address: Permit number: o?p/3=p-, -37 0 PO Box 66 3 Crystal Bay, MN 55323-0066 Date received; -J_ 16, -3 A y Street Address: Received by: ___6J t 2750 Kelley Parkway Plan review fe : its tt� SRo ��,�' I Orono,MN 55356 Total Fee: / /60 Main: 952249-4600 Fax: 952-249-4616 www,ci.orono.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: 1130 �� Wll�ow 0� Job Site Address: Will this be a Parade of Who ties,Remodelers Showcase Home or other Display Home? ❑ Yes j No If yes,a special event permit is rikulraa with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless app!cant demonstrates sufficient on-site parking is available. Non permitted events wilt not be allowed. CONTRACTOR/APPLICAN INFORMATION: -- Name: 50,404,14,4,- 814nded4 **S, C. State License# BGG?' (39 Expiration Date: 3-31-1 if Lead Certification Number: I No pcilft Expiration Date: (for work on homes that ware constructed prior to 1978 Phone: (cell) 763 -63q - alga 2„ (office) Mailing Address: '700( ea.';we'd LN /Ir Cit : ,. -._ .le Gwe ZIP: 5S'S Contact Person; Vi'Cr.R $k,j xh. Applicant is: Contractor / Homeowner (circle One) Email and/or Fax: sw•0.4T'644 e.44$/4N@ 541.m.ii,co Ai 1 PROPERTY OWNER INFORMATION: Name: _t7.. 11 • OW h4c4AV Phone (day): 611— 2. 2. --6334 Address: $272. 51-o,ve QReeic OR City: C.44.01masse„,ZIP: £S I7 Email and/or Fax: PROJECT INFORMATION Overall .ro ect descri•tion: _ _ Type of Protect: Any earth movement may also require MCWD review&permits: ❑Door(s) El remodel IDFire Damage Minnehaha Creek Watershed District(MCWD) XRe-roof,asphalt ❑ 3epair ❑Storm Damage 18202 Minnetonka Blvd El Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952471-0590 ❑Re-roof, other(specify) ❑siding ❑Other: (specify) Fax: 952-471-0682 ❑ IS.lindow(s) www.minnehahacreek.org Estimated Construction Vadation of Project(excluding land) $ 1,000 APPLICANT ACKNOWLEDGEMENT: + Agrees to provide all information required or requested by the Building Department; ▪ Certifies that the informatiofl 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( 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 sum the inf rmati,;,.p:• application may not be issued. Applicant's Signature: ��>, Date: 5-/S-/3 Owner's Signature: . _ Date; Last Updated:03/06/2013