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10/30,/2613 11:57 7635371882 STANDARD PAGE 02 City of Orono Building Permit Application for Maintenance I Replacement / Renavatian (No structural expansfon. Oniy windows, doars, siding, re-roof, etc.) ��0 Mailrnq Address� Permit number: �{ " D �� PO Box 88 Crystal Bay, MN 55323-0086 �ate�eceived: ��'3 — Street Address Recaived by; � � 275p Kelle Parkwa �- Y Y Plan reviaw fae: `�� u Qrono, MN 55356 �K�SF�°� Totel Fee; �D� g� Main: 952-249-4600 Fax: 952-249-4618 n .mn. This application form must be completed in full and all raquired information must be . Incomplete applicatlons wlll be returned. (Please print) �D�• l'i(� GENERAL INFORMATI� ' ,�� ,� I � -1 Job 8ite Address: �� G� Will this be a parade of Homes, Remod�l Showcase Hvme or other Disptay Home7 Yes Nb !f ye9,a specia!event permit!s repulrOd wlth PollCe Dep�rtment and City CounC�!approva160 deys prior to the e�Or+t. Shunle bus servlce will be required unless epp�iCent demonstrates sufflcfent on-site parking;g avaflable. Non-permitted events wi!!nOf be alfowed. CONTRACTOR/APPLICANT INFORMATIC�N: Name, �- �. � �UVltv'�� 5tate License# C (�jp�� Z Expiration Date: I �ead Gertificatipn Number: y�q.� -� �C.{3(�� Expiration Date' S� (for work on homea that were canatructed prlor to 1978 Phone: (celq (offic�) Mailing Address: City: ZIP; Contact Person; Applicant is: Cantractor / Hnmeowner �c�►a•on.� Email and/or Fax� PROP�RTY OWNER INF�RMA`�ION: Name: ��t� 1�'l.�c ��SKl Phon�(daY) T �c�� 11 Addres5: 1� Vy-�� City: ZIP: �mail�nd/or Fax' PROJECT INFORMATION: Overal! ro'ect descri tfon; 1`ype of ProJeCt: Any earth m�vement may alea requlre Q Door(s) �7 Remodel ❑ Fir�Dama�e M1��Wp revlew�permlta: �Re�roof, p�phalt ❑ Repair �Storm Damage Mlnnehaha Craek Watershed District(MCWD) 16202 Minnekonka�1vd �Ra-roaf, cedar ❑ Restoration �Water Damege Deepheven, MN 55391 ❑ Re-roof,other(apacliy) ❑Siding ❑4ther: (specify) Phona: 952-471-0590 Fax' 952-471-0882 �Window(s) w. innehahacreek.o Estimated Constructlon Valuation of ProJect{excludfng land) $ � �. APPLICANT ACKN�WtEDGEM�NT; . Agrees to provide all information required pr requested by the 8uilding Departmsnx; . Certifies that the information suppliad is true and correct to the best of hia/her knowledge. The applicant racAgnizes that they are solely responsible for submitting a Complete application being aware that upon failure to do so, the staff has no alternetive but to rej�ct it until it is campl�te; + 5ome or af1 af the information that you are asked to provide an this appllcation is elasaified by 8t8t8 Isw es either private or cunfldentlal. Prlvate data is ir�formation wnich ganerally cannot be given ta the pu�lic but cen bc given to the subject o}the dat�. Conildentfel data Is information which generally cannot be glven to either the public or the subJect of the data. Our purpose and intended use of this infnrmaUon is to annually update aur records and records of other gpvernmental agencies required by 1aw. If ou refusa to su I the informgtion the IiCatlon ma not b�issued. Applicant's Signature: �ate: /�Q Owner'a Signature: , Date: Last Updated�03I0812013