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11) /, Gi3 , 3 9 <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) G <br /> A, Mailing Address: Permit number: 0.20/S- �2 O 9 <br /> 0 <br /> '�- {V PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: /0-l.-/5-- <br /> Received <br /> S <br /> Street Address: Received by: 7 1 <br /> Z 2750 Kelley Parkway Plan review fee: 67/4457 <br /> �tf ��L Orono, MN 55356 020/5-0/.2- SS <br /> kESNO Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: c� (� <br /> Job Site Address: $7-0 013` Cts' b=� r Tei S• • <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes X No <br /> 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 <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT' INFORMATION: <br /> l <br /> Name: -LAS <br /> State License# d�/,4. Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 7f03-2810-2-4f29 (office) ` s2_-9Zto--09? x/( <br /> Mailing Address: g2-e. OP C1,70. 1 3,7 29 S_ Oreo, ZIP:OrZIP: 537f <br /> Contact Person: 45. 4 _ c Applicant is: Contractor / Homeowne (Circle One) <br /> Email and/or Fax: c-S e- zxc� s..c <br /> PROPERTY OWNER INFORMATION: n �J <br /> Name: -nS 4. kL 4 c <br /> Phone(day): '74,:-ZZ-.7J(2`/ <br /> Address: $"ZO OI.& e►73�4 g.., S_ City: Ort ZIP:5—37 f <br /> Email and/or Fax: 14-c.ret_s wok 9eore-xe..pe-s.L.,-.._ 1 t 1 n <br /> PROJECT INFORMATION: Overall project description: Von. � i�� k K+a1� A- M`^F92�r''\ tom'` <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) aRemodel 0 Fire Damage MCWD review&permits: <br /> 1:1Re-roof,asphalt ❑ Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar 0 Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) 0 Siding Egr Other: (specify) Phone: 952-471-0590 <br /> pp Fax: 952-471-0682 <br /> 0 Window(s) or' n 4,;,47:461 www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ fl 96 RFCFIVFI) <br /> APPLICANT ACKNOWLEDGEMENT: OCT 0 6 Z015 <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant l tbset4tilimare <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff s no arter`n'afiive ut to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the informati•, he application may not be issued. <br /> Applicant's Signature: ctAlli.'� Date: /a`)----/r <br /> Owner's Signature: a�— � Date: (6-5--/--V-- <br /> Last <br /> 5--/--V--Last Updated:January 2015 <br />