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AUG124-2�'11 13:20 From: 6785736615 To:9522494616 Pa9e:1�1 City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Addr�ess: Permit number: �//- '�! O,g,Q�O PO Box 66 Crystal Bay, MN 55323-0066 Date received: � � / e -� St►�etAddress: Received by: �� G� 2750 Kelley Parkway Plan review fee: ��,EBxo� Orono, MN 55356 7otal Fee: /3�� Main� 952-249�600 Fa)c: 952-249-4616 www.ci,orono.mn.us This application form must be campteted in full and all required information must be submitted. � �� Incomplete applications will be returned. (Please print) GENERAL INFORMATION; Job Site Address; 3�� [��J� l�L �r�'`�b �^� �s� � Will this be a Parade of Homes, Remodelers Show ase Home or other Display Home? Yes � No lf yes, a specia/event permit is requll'�d with Po/ice Department and City Councll approval 60 days p�iol to the event. ShutNe bus s�rvice will be required un/ess applicant demonsfrates su�cient on-site parking is available, Nor1-perm�tted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: �� v� State License# r� �,�,[� � 'Z,p S'°�3 b�` Expiration Date; '1 �Z Lead CeRification Number: Expiration Date: (for work on homes thet were constructed prior to 1978 Phone; �'L� "t o�� (office) (cell) Mailing Address: 'j�b(o ��0/ � City: v ZI P: ��Z Contact Person: Applicant is: Contractor / Homeowner (Clr�cle One) Email and/or Fa�c: ��{� � �� [,,r��v.. -L0 w� PROPERTY OWNER INFORMATION: , Name: _N�c�. �.1�►�Q..v�S Phone(day): �S'Z - �l�'�- �Q��g__ Address: �-3�j�3 Gln�rrN p�v� C�tY: �f"o„�� ZIP� $S"3�p Email and/or Fax PROJECT INFORMATION: 7ype of Project: Any earth mevement may require MCWD�eview�permits: ❑ Door(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed Distric4(MCWD) t�Re-roof,asphalt ❑ Repair I�torm Damage 18202 Minnetonka Blvd ❑ Re-roof,cedar [�F�estoration ❑ Watar Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re--roof,othe�(spec�ty) ❑Siding ❑ Other. (specify) Fax' 952-471-068�2 ❑Window(s) �-minnehahacreek.or4 Overall Project Descri tion: - ca � �o.- Estimated Construction Valuation of Pro�ect(excluding land) $ S, (�q , � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Departme�t; • Certifies that the information supplied is true and correct to the best oi his/her knowledge, The applicant r�cognizes 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 reject it until it is mmplete; • Some or al) of the information that you are asked to provide on this application is cfassified by State faw 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 date. Confidential data is information which generally cannot be given to either the public ar the subject of the data- Qur purpose and intended use of this information is to nnually update our records and records of other governmental agencies re uired b law, If ou refusg to su I the inform bn,the a lication ma nat be issued. n....l:......ai.. C�......�.iri. �� \ \ � nafP' V'�/ /.M / � I