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Jul, 2. 2012 12; 40PM No, 9248 P, 1 City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) �-1 MaiJing Address: Pertnit number: a O►a - 0�(p a O:¢,Q�.O PO Box 66 Crystal Bay,MN 55323-0066 Date received: Z-2- I 2- � �' �, Strael Address; Received by; � �, � G� 2750 Keuey Parkway Plen review fee: �k��o$4� Orono,MN 55356 =-_—= Total Fee: �(� , 2.� Main; 952-249-4600 Fax: 952-249�616 �, i.orono.mn.us 7his applicstion form must be completed in full and all required information must be submitted. Incomplete applicatlons wlll be returned. (Please print) GENERAL INFORMATION: " Job Slte Address: f a cl C-� �� y L.rC�� ` � J `� Will this be a Parade oi Homes�Remodelers Showcas Home or other Dlsplay Home? Yes o H yes,a special evenf pem'ilt is r�equiied with Pollce Department and City Council approva/60 days prior to the event. Shuttle bus servlce wilf be required unless applicant demonstra�es sufficient on-site parking is available. Non-pennitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: � c� 4� �2�,L �� State License# C ,�3 ,�� c; Expiration Date: �� /� �f� Lead Certificstion Number: f{ T �� (e;3 •�S,_� Expiration Date: � � (f�r work on homes at were conatructad prror to 9978 Phone: �5 - `"1_l (office) �S � - �- tQ d� (Cell) Mailing Address: �� '� - �„ ( „ City: o ZIP: �S y Contact Person: �,,.z_ � ��.5�,;�.�s �-� Applicant is: Contractor Homeowner ic,�ia o�o� Email andlor Fax: �S ,� �� -� � °� O PROPERTY OWNER INFORMATION: Name: � �e. �,� S�� + (s' t' a PhOne(day): �' S S� " 4 �3-- ��)�`'r City: Q 2� � ZIP: S.�3 �-_� Address: � a � �, C �,, �., C�c,a.�, Email and/or Fax h (� c � � �= (o� � �a� 4 ^ �� PROJEC7 INFORMA710N: Type of Project• Any ear�movement may require ❑Door(s) ❑ Remodel ❑ Fire Damage MCWD revlew 8 permits: Minnehaha Creek Watershed District(MCWD) ❑Re-roof,asphak ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven,MN 55391 ❑Re-roof,cedar ❑Restoration ❑Water Damage Phone: 952�71-0590 Re-roof,othar(ap�clfy) 0 5iding ❑Other; (specify) Fax: 952-471-0B82 • www.minnehaha�@k.orq � A v_� ❑Window(s) Overall ProJect Descriptlon: � 0�w ..�� >. . . _ �v �� S f . �, Estlmated ConstrucNon Valuation of Project(excluding land) S /�� „ J'� _ APPLICANT ACKNOWLEDGEMENT: • Agrees to provide ell information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recogni�es that they are solely responsible for submitting a complete application being aware that upon Failur�e to do so,the staff has no altema6ve but to reject it until it is complete; • Some or all of the information lhat you are asked to p�ovide on this application is classified by State 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. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our pur�ose and intended use of this informaGon is to annually update our records 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. ��,��Q�e �ate; ��""a � �� Applicant's Signature: � . �. �.�. / �__a��_�_�_�. n0 RIf�1l1A� . .