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0 City of Orono Building Permit Application for Maintenance / Replacement / Remodel - Residential ONLY (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) T Mailing Address:�O2_ — r)vC 1 YO PO Box 66 Permit number: C�I L �11-I Iia-rt-* Crystal Bay, MN 55323-006Date received:�� c� Street Address: Re by: � �tL rc L�9G yG� 2750 Kelley Parkwa ( ��, p _ J� F` krS H O�� Orono, MN 55356 � I�- Total Fee: p, Main: 952-2494600 Fax: 952-249-4616 www.ci.orono.mn.us fffjjj [[ This application form must be completed in full and all required information must be submitted. GENERAL INFORMATION: Incomplete applications will be returned. (Please print) p Job Site Address: I I gS ( yotY MERE- 'JZoA-D vJfrYzk r f! N Sa l Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o 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: ST(zF_LTE 2 A- Ar SScGIrfjT�� State License# e�c_—bot Stip Expiration Date: 3/3( Znr Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) (,12 - 7"Z3--3re5g3 (office) 952--3q(a-Zif 9 Mailing Address: t 3Q- tMl00b;TQ A D> City: ,3AF ZETA ZIP: 55.3q Contact Person: ki`' 5cHi2o Applicant is: ontrac o / Homeowner (circle One) Email and/or Fax: k5c4%;ro Q GreehPr %omen-(ori PROPERTY OWNER INFORMATION: Name: T©n}Y > Mt(HE/.[ E fyLRZLU Phone (day): Address: f i$S W`fn,p,fn6;9,(= P=V" City: y-)1+yZAT-4 ZIP: . 39/ Email and/or Fax: PROJECT INFORMATION: Overall project description: �` �ecc__� 5F: ,i�yd Type of Project: Any earth movement may also require ❑ Doors Remodel MCWD review&permits: ( ) El Damage ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) F1 Re-roof, cedar 15320 Minnetonka Blvd ❑ Restoration ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.org Estimated Construction Valuation of Project (excluding land) $ / '75f000 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 thq information, tkpApplication may not be issued. Applicant's Signature: Date: 511&1Z0 Owner's Signature: Date: Last Updated:January 2016