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. � City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, �e-roof, etc.) _—_�:\ Meiling Address: Pertnit number: o2D/�•O/a a7 O;�D�O PO Box 66 • Crystal Bay,MN 55323-0066 Date reoeived: � �'�� '� .` Street Address: Received by: � 2750 Kelley Parkwey Plan�view Fee: �� ' prono,MN 55356 � �tlo�% �pZ�.�J v -=_--= Total Fee: GJ Main: 952-249�600 Fax: 952-249�616 www.ci.orono.mn�us This application form must be completed in full and all required infornladOn must he submitted. 75�� Incomplete applicatlona wlll be�tumed. (P/g8se p�nt) GENERAL INFORMATION: G Q f� u� SO� I Job Site Address: Z J v f�D�✓> >� �� WIII this be a Parade of Homes, RemodeleB Showcase Home or other Dlsplay Flome? Yes No !f yas,a special event permit ia ngquired w/th Polke Depa�tment end City Council approval 60 days Drior to the evant. ShuKle 6us service will be , repuired unless applieant demonstrates s�cient on.site pedcing!s avails6le. Non-pemritted evenfa will not be allowed. CONTRAGTOR/APPLICANT INFORMATION: Name: I I A� ��n PrC Sl.r,�h �. State License# � � s S Expiration Date: �'3 3 I �3 Lead Certification Number; N T- �a 2�,ti~l Expiration Date: oq Zq �2 C� S _ Phone work on homea thet w�ere c�o�3 t�ed�Nor a9�8 (O��} G�2',�'3 S'-� �,�v (cell) ..� 1 '-/ Mailing Add�ess: -�Z� `Tp,,�Q,/ � Clty: � ;y,s� ZiP: 553�10 Contact Person: �;;L� e�v.p�,� Applicant is: racto / Homeowner (Clrele One) Email andlor Fax: ! r;c k.�Q� �'q ��a�I• c.�.'w. $D 0 -�l ��1-� 2Z PROPERTY OWNER INFORMATION: Name: Rc'p�-�pY= Ga.r+�n Jo�r S 61n Phone(day): �S Z-g u y— I S ON Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: -- Type of ProJect: Any earth movement may requlro ❑ Door(s) ❑ Remodel ❑Fire Oamage MCWD review 8 pennits: Minnehaha Creek Walershed Disirict(MCWO) �Re-roof,asphalE �aepair ❑Storm Damage 18202 Min�etonka B�vd (�Re-roof, cedar - Deephaven,MN 55391 ❑Resto�ation water�amage Phone; 852-471-0590 ❑Re-roof, othe��speclfy� ❑Siding ❑Other.(speciFy) Fax: 952-471-0682 ❑Window(s) _� �mi nehahacreBk.orcl Overall ProJect Descrlptfon: � Estlmeted Conatruction Valuatlon ef ProJect(excluding land) S S�0�p,00 , APPLICAN7 ACKNOWLEDGEMENT; . Agrees to provide all infortnetion requirod or requested by the euiiding Department; � . Certifies that the information supplied is true and correct to the best of his/her knowledg . The applicant recognizes that they are solely respo�sible for submitting a complete application being aware that upon failur to do so, the staff has no altemative but to reject it unii{it is complete; • Some or all of the information that you are asked to provide on this application is classjfied by State law as either private ar confidential. Private data Is information which ge�erally cannol be given to lhe public but can be given to the subject of the data. Gonfidential data is inFormalion which generelly cannot be given to eilher the public or the subject of the date, Our purpose and intended use of this infortnation i5 lo annually update our reco�ds end reoords of other govemmental agencies re uired b law. If ou refuse to s rmation,the a liCation ma noi be issued� Applicant's Signature: Dete:' �Z� .� ��- v-' L� Last Updaled: 08-09-2011 l d 89Z0910889 '�N/90� � '1S/�0� £ Z lOZ 9 �34 (�Hl) � WOa�