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Jul. 24. 2012 11 : 54AM No, 9335 P, 1 . City of Orono , Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mai/ing Address: Permit number: O.g,O�O P�Box BB Crystal Bay, MN 55323-0066 Date received: r ' ;r ,, Streel Add�ss: Received by: �� G�' 2750 Kelley Parkway Plan review fee; i � Orono, MN 55356 ��H�¢' Total Fee: Main: 952-249�600 Fax: 852-249�d616 www.ci.orono.mn.� This application form must be completed in full and all required information must be submitted. Incomplete epplfcatfons will be returned. (Please printJ GENERAL INFORMATION: Job Site Add�ess: q?� � C C��P � ��-� � � Will thls be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No Nyss,a specia�event permit is required wirh Police pepartment and City Counc;l approva160 deys prio�to the event. ShutNe bus servioe will be required unless applicanf demonstrates sufficient on-srte parla�ng is available. Nony�ermitted events will not be ellowed. CONTRACTOR/APPLICANT INF�RMATION: Name; �' �h e� ` �3 .�.�. State LiCense# � C � 3 y 3 �, � _ Expiration Date; — _ Lead Certification Number:�y A� a (p '3 a5—I F�cpiration Date: r-(-a 3 r�s (for worJc on homas that were construct�d pNor tn 1978 Phone: - (office) (Cel l) Mailing Address: o�s 1� , ��ty: ZIP: 3 Contact Person: y3 c.�� Applicant is: nNact / Homeowner �ci►�ia o�o► Email andlor Fax: Cy S �—�� _(�, � PROPERTY OWNER INFORMATION: Name: � � � rt2.z-t�' Phone(day); �- � ' Address: �La C__ _c,�.y�w p-t , 1�•� Clty' p�t_s_,,J � ZIP: S $3� Email end/or�ax • PROJECT INFORMATION: , . ., Type of Project Any earth movement may require MCWD revlew g permits: ❑Door(s) ❑Remodel ❑Fire Damage Minnehaha Greek Watershed District(MCWD) ❑Re-roof, asphalt ❑Repair ❑Scorm Qamage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑Re-roof, cedar ❑Restoration ❑Water Damage Phone: 952-471-0580 ❑Re-roof,other(apecl(y) �Siding ❑Other;(specify) Fax: 9521171-0662 www.minnehahacr �k.om indaw(s) Overall ProJect Descriptlon' � ��cA a � � �� o..�5 Estlmated Constructlon Valuation of Project(excluding land) $ '3 0 � q o� APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all infortnation required or requested by the Building Department; • Certifles that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so.the staff has no alternative but to rejeot It until it is complete; • Some or all of the information that you are asked to provide on this application is dassified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given �o the subjecl of the data. Confidential data is information which generally cannot be given to either ihe public or the subject of the data. Our purpose and intended use of this information is to annually update our tecords and records of other governmental agencies re uired b law. IF ou refuse to su I the information the a lication ma not be issued. Applicant's Signature: ,f�,1 � �- Ci-..�.a.�,� Date: �/ �'��'I 2___ _