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�� . Ci�y of Orono � Building Permit Application for Maintenance 1 Renovafiion � (windows, doors, siding, re-roof, etc.) Mailing Address: permit number: ! O��,j�O PO Box 66 Grystal Bay, MN 55323-0066 Date received: a� �, Street Address: Received by� �� 2750 Kelley Parkway Plan review fee� � �9x�xo4.� Orono,MN 55356 — Total F'ee: p� 'S� Main: 952-249-4600 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: � Job Site Address: g � � � s �✓ Wil1 this be a Parade of Hom s, Remodeler^s Sh wcase Home or ot er Display Home? ❑Yes No If yes,a speclal event permit!s requrred wilh Police Department and City Council approval 60 days prior to the evmnt. Shuttle bus seivrce wi!!be required unless app�icarrt demonstrates s�cienf aR-site parking is available. Non-permhted events wrll not be alloWed. CONTRACTOR/AP�pPLICANT INFORMATION: � Name; T�'G L'1?1+��YV�� 01� C �.��,"I-7��1�l�V�S �e.P'�/�L-l� �./J L State License# � � Expiration Date: 'j� 3 � -� j 3 Lead Certification Number. N�—r� � 11 �(-- � Expiration Date: � �� .� -�1,� (!or work on homes that were constructed prior to 1978 Phone� ��,�.• y L_�- �'Z4 3 (office) (cell} Mailing Address: � a„5 � � � � �ie � ,�. (_ City: �aK �ic.5 ZIP: �37� Contact Person� . Li�� e Applicant is: n rac / Homeowne� �c��oi.o�.� Email and/or Fax: ��o�,;�., � �A c c. - Q , c�� PROPERTY OWNER I�ORMATION: � Name; ��,� � Phone (day): , _ � Address -�-��(ts' 3 v��s��t Icy, City: �ro�n J ZIP: rjs��(o Email and/or Fax ' PROJECT INFORMATION: Type af Project: Any earth movemant may�equire ❑Ooor(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: Minnehaha Creek Watershed District(MCWD) �e-rooF,asphalt ❑ Repair !$'Storm�amage 16202 Minnetonka Blvd ❑Re-roof,cedar ❑aestoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑Re-roof,other(specify) �Siding ❑Other: (specify) Fax: 952-471-0682 ❑Window(s) www,minnehahacreek.orq Overall Project Desc�Iptfon: l � �i ��v4�r �.� �r..�..�,w,.e;ti-�-- Estimated Construction Valuation of Project(excl ing land) $ l?�,��u .'� 2? APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building �epartment; • 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 altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is cfassified 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 subjeot of the data. Confidential data is inforrnation which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this inforrnation is to annually update our records and records of other governmental agencies r uired b law. If ou refu I he information, the a lication ma not be issued. Applicant's Signature: Date: �'�j�� ' Last Updated� 08•09-2011 l 'd 11�5 'oN uoi ��ao�sa� � uoi ��a �suo� �y Wy��Ol IIOZ 'lE '��d