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Sep.28.2015 06:41 AM Dakota Craftsman 6127600628 PAGE. 1/ 1 _.... . � City of Orono Building Permit Applica#�on for Mainfienance I Replacement / Remodel (t.e. windows, doors, sidin , re-roof, etc. � NO STRUCTURAL EXPANSION) Mailing Address; C � ,� Z � ��0 PO Box 66 1'ermit number: , i I.� Crystal Bay,MN 65323-0086 Date recelved: `� �2 0�� StreetAddress: Received by, �_.��Q y � 2750 Kelley ParkwBy Plan reviewfea: � �— I �� • `� � Orann, MN 55356 �/�� (�'�F S N��'"� � �� `T t Total Fee: M�in: 952-z49�600 Fax: 952-249�3616 www.ci.orono.mn.us This application fvrm must be completed in f�Ul and all requlred hiformation must be submitted, Incomplete applicatfons wlll be retumed. (Please print) GENERALINFORMATtON:�� Q�SG�� . Job Slte Address: � Wlll thls be a Parade of Hnmes,Remodelera howcase Home or other Display Home7 Yes Nn !f yes,a special evanf pe�mrt is required with Pollce D�palfmant and Glty CouncN epproval 60 days pnor to the event. Shuttle bus service will tre raqulled unless applicant damonstrates suffrciant on•slte parking!s avalla619. Npn-pArmQtAd eV�nf6 Wl1I 11ot bB allOWed. CONtRACTOR/AP ICANT INFORMATION; Name: �-q State Lipense# 4 G Expiration Aate� - � r Lead Certification Number: Expiration Date� (for work on homes that were consfnrcted prlor to f97d Phone: (cel!) Q� (offlce) Mailing Address: � ��U City: ��py^ ZIP: � Contact Persan: u Applicant is ontrac o / Homeowner (Clrcl�on�) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: � �h 1 Phone(day): ..,�5,�-4�3�. d�, p� I I Address: L(37� f�uStC�C -�o� --- -- --- C{ty: I1�L1�1� �lCfc,ll�' ZIP: T Email and/or Fax: PROJECT INFOFtMAT10N: overall ro ect descrl tion: 7ype of C'roject: Any earth movement may also requlre ❑Dovr(s) ❑Remodel ❑Fire�amage MCWD review 8 p�rmitg: Mlnnehaha Creek Watershed plsMct(MCWD) ❑Re-roof,asphelt ❑Repair ❑Storm�amage 18202 Mlnnetanke Blvd �Re-roof,cedar ❑Restoration Q Water Damage Deephaven,MN 55391 ❑Re-roof,other(specifar) �Siding Q Other:(specify) Phone: 95z-471-0590 Fax: 952-a71-0682 �Window(s) www,minnehahacreek.ori� �stimated Construction Valuation of Projeck(excluding land) $ �,Ck�`--"=- �� T,�„ APPLICANT ACKNOWLEDGEMENT; �C� G'C�C� DC5 . Agrees to provida al)information required or requested by the Bullding Department; • CBrtffleS that the Intortnation supplied is true and correct to the beat af hlslher knowledge. The appUcant recognizes that they are solely respansibfe for submitting a complete applfostion 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 fniormatlon that you sre asksd ta provide on this application is classified by State lew as either private or confidential. Private date Is lnformation which generally cannot be given to the public but can be glven to the subJect of the data. Confidentia)data is informatinn whloh generalty c8nnot 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 ou refuse fo su I ihe I atlo thg 8 (ication ma not be issued. Applicant's 8ignature: pate: ` 2� 1 �ulS Owner's Signature: �� Date: �'-' � ��G�S Last Updated,January 201b