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- City of Orono Building Permit Appiication for Maintenance i Replacement / Remodel ,�"� O "' Mailing Address: Permit number c�/�� U U ;% �- N��\ Po aoX ss � ! � Crystal Bay,MN 55323-0068 Date received: �U"� �- S i � ,! Sheet Address: Received by: y`�� :/' 2750 Keiley PaiicwaY Plan review fee: G ' Orono,MN 55356 {� \\lqkFSH��E-�� '��U� �1___-- Total Fee: Main: 952-249-4600 Fax: 952-249-4616 This appfication form must be completed in fu11 and all required informati�n must be submitted. incamplete applications will be returned. (Please prinf) (3ENERAL INFORMATION: . 1 Job Site Address: 3 a� 7 �SC:.�b �t �'C-1� Will thls be a Parade of Homss, Ramodelars Showcase Home or other Display Home? Yes No !f yes,a speda/ev�ent pemM is n�quirod widh Police Depafinent anaf Cily Council approva/60 days prror to the evertt. Shuttle bus seivioe wili be required unless applrcant demonsbates sulFrcient on-site parking!s avaAable. Non-pennitt�ed events wiN not be allowed CONTRACTOR/APPLICANT tNFORMATION: Name: So r�c�e.r' a.ar� �o r�.i er' j�c.c%1 cp�'S L L�C'_� State License# xpiration Oate: 3 — 3 � — 17' Lead Certification Number• Expiration Date: (for work on homes thaf were constructed pHor fo 19T8 Phone: (celi) 612-L�3�!�l-�-!18 7 (office) 952- �f�3-�3 �/9 t Mailing Address: p X Q� City: �J��. r�a� ZIP• � Contact Person: s'b►�e r c�,Cx.f' Applicant is: Coniractor / Homeowner �ci.�e o�e� Email and/or Fax: ' Sp n et- M a i • �m PROPERTY OWNER INFORMATION: Name� �p�v� �- �j� �`�"r'►.�G�G Phone(day): 95�- Z�.I-05�3 Address: �Q(p 2. ►�(o,r-r 2rn �v�n u� ciry:$�p,�i nq Pc�,r'�S z�P� SS.,3 8 Y Emai!and/or Fax: 5-}-r�LLG 'SS3 S y(� 4�'►'+Ct�. c-o M � �y,�p�le, "oo� PROJECT INFORMATION: Overail ro ect do� tion: C.'b-L�� " 5�cRe Y'oU�adr� it7�►u�C�OS Type of Project: ' �/ , A�y esrth movement may also require �,��`� MCWD review&permits: � �Q door(s) ❑Remn� I � �mage �Re-roof,asphalt r' 'i��i�' l ,�li emage Minnehaha Creek Watershed District(MCWD) � 18202 Minnetonka Blvd ❑Re-roof,cedar . �k/ �� j„�� nage Deephaven,MN 55391 t"'- � V� Phone: 952-471-0590 ❑Re-roof,othe�(specity� , p � �fY) Fa�c: 952-471-0682 U✓� �� Estimated Construction Y, ��';,`I�L� �andj 8 �-� � � APPLICANT ACKNOWLEL �' . Agrees to provide all informa ,.�red or requested by the Building Department; • Cerfifies that the information supplied is true and correct to the best of hisltier knowledge. The applicant reoognizes that they are solely responsible for submitting a complete application being awa�e that upon failure to do so, the staff has no attemative but to rejed it until it is complete; • Some or atl of the informatiori that you are asked to provide on this application is classifled by State law as either private or confidential. Private data is infoRnaGon which genera(ly cannot be given to the public but can be given to the subject of the data. Confiderttial data is infvrmation which generaNy cannot be given to either the public or the subject of the data. Our�rpose and intended use of this infiorm 'on is annually update our records and records of other govemmental agencies required by law. If ou refuse to su I n Rna� .the licatiom m �ot 'ssued. ApplicanYs Signature: _ Date: 0�'�" �S� 2-�� Owner's Signature: Date: � l�� 2�- Last Updated:January 2015