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Jan 21 16 02:56p Craftmasters Remodeling 6517574106 p.2 � • Cityof Orono Builcfing Permit Application for Maintenance / Replacement I Remodel — Resfdential ONLY . _ _ .n t-. .;� .- ., - „ _ ��.. .�� _ __�.. e � ,�,. � �...� . :;,,...F , . , ,.,� - ... e..� �,: .d<..-' ' �`�.._ -. ',_...._-._.._....., . , Mailrng Address: � �` � ��4-D�O'�. PO Box 66 Permii number: �' /, _, I 4 • Crystal Bay, ti1�55323-(}a66 Da[e received� ;i '� �`�'I �- ;�"i♦ ! ' Street Add�ess' Received by: - i,� `�,%� + �% 2750 Kelley Parkway Plan review fee: �' r�, � �:"� Orono, MN 5535fi �.,��c�.tn��'�i TOtal Fee: �-��' �" � Main: 952-249-4604 Fax: 952-249-4616 ��.��rr.r;_c,ro��o.;��.�,:s This application form must be completec#in fuil and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL]NFORMATION: r1 Job Site Address: I �� 3�1 Ctit2 � ' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? � Yes o Jf yes, a spec�a!evenf pe�rnit rs required with Polrce Departmen[and Ciiy Ccunci;approva!6Q days prior to the e venG Shuf,`fe bus service riiU be requi;ed unJess ap,olican(dsmonstrates sufficient on-srte parking is avarlable. Non-permit`ed events wifl not be a'loweo, CONTRACTOR!APPLICANT INFORMATI�?N: ' Name: �;{ZCrr-�iw;:2a-{-"�`7 I(l.:"�','� k.�i��-. State License# L Z� "Z Expirakion Date: ?7l 2�;l� Lead Certification Number: Y'� ��.`�" - <�z ---�--�_ 2 Expiration Date: � Z�G� ( 2GZ�,. (for work on homes that were construcfed prior to i978 Phone: (cell; {offce) �j� --� c] 7_ �-�-f L� A�ailing Address: 2�-�C''S`.� s 1C�.k„��44� �._�':�:� L Contact Person: ir..� ;�;`'�;• ��- c_s-1 Applicant is: �on ractor�J Homeowner (CirGe OneJ L '� -� . - EmailandrorFax: ��C1-4�-��= ��1L=2�.1...ii`�:1� C�..C:�,t�G..��.. � ��.`r�'"7 (�,'�l-��V7 - LEII%(� PROPERTY OWNER INFORMAT{ON:�� Name: ��`_'��'1 tC.�-ti��-- Phone(day): � � Address: ] '�.-��' t�;u�.`�.� . c�iy:� ��'lf`' ziP: �r� �Z3 Email and!or Fax: PROJECT INFORMATION; Overall project description: Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑ Flre Damage MCWD review&permits: ❑ Re-roof,asphatt ❑ Repair ❑ Storm Damage f�linnehaha Creek Watershed Cistrici(MC�ND) 15320 Minneronka Blvd ❑ Re-roof,cedar ❑ Resicration ❑Water Damage Ivlinnelonka,�a1N �534b ❑ Re-roof,other(speciFy) ❑Siding ❑ Other.(specify) Phone: 952-471-0590 Fax 9b2-471-0682 �Window{s} :y��h�.,�tfnn�..�._.._..__�_._ c��°�. � ., a�; .. T ,a .ai�� C ,...._ Estimated Construction Valuation of Project�excluding IanB} $ T� � APPLICANT ACKNaWLEDGEMENT: __ _-� • Agrees to provide all information required or reques[ed 6y the Building Depar.ment; • Certifies thaE the information supplied is tr��and correct to the best of his/her kno�viedge. The applicant recagnizes that they are solely responsible for submit�ing a complete application being aware that upon failure to do so,the staff has no alternative �ut to reject it until it is camplete; • Some or all of the inforrnation that you are asked to provide on this application is class fed by S:ate law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidenf�al data is information which generally cannot be given to either the public ar the subject of the da:a. Our purpose and intended use oP this informaticn is to annually update our reeords and records o`other governmental agencies required by law. If vou refuse to su I the information,the a licalion ma nol be issued. r� —� �: �� ---�- r Applicant's Signature`• � ��-� � �"�J\ � �-- Date: �--1`=�� 1 l �C�� ' Otivners Signature: oace; Last Updated January 2016