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AU�-19-2011 12:38 From: 6785736615 To:9522494616 Pa9e:1�1 . . . City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number. � I—f> v� O�,��O PO Box 66 Crystal Bay, MN 55323-0066 Date received: a / a Street Address: Received by: �`,Q, � 2750 Kelley Parkway Plsn review fee: ��S�o$� Orono, MN 55356 �j Total Fee: �� Main� 952-249-4600 Fax: 952-249-4616 www.ci,orono,mn,us This application form must be completed in full and all required information must be submitted. �, a � v O Incomplete applications will be �eturned. (Pleasa print) � GENERAL INFORMATION: • . � ��'�- Job Site Address: 3�� r� PL� f c V�, Will this be a Parade of Homes, Remodelers Showcase Home or other�isplay Home? ❑ Yes ❑ No If yes,a special event pe�mit is r�+quired uvith Police Aepartment and Cify Counci/approval 6�days prior to the evenf. Shuttle bus service w111 be �equired unless applicant demonstr�tes sufficient on-site parking is availHble. Non-perm(tted events will not be allowed, CONTRACTOR/APP� �reMT IAGFORMATION: � Name: � d Y1 State License# Z,os q 3 ��-� Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that were constructed prfor tu 1978 Phone: (��a_�(�� - -1��o (office) (ce��) Mailing Address: \2'3�0�0 (+�.�Q�I QSc�c� g�VG� C�h��'�i��5v��,la- ZIP: �'��"'� Contact Person: J�a�_ __ __ �Applicant is: ontract / Homeowner �Circ�e One) Email and/or Fax: �� ,�,�,��py��- �,�� Lv y�,� PROPERTY OWNER INF�RnnaTinN• , Name: �,�i ,�e��S'��n�. � Phone (day): 9�'L• 3" 3Z�O � Address: �`�t�� CL��r4�.�C1��'� c�ry=c7ra�o ziP; �'�'3s� Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: Minnehaha Creek Watershed District(MCWD) �Ra-roof,asphalt �epair [�torm Damage 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0B82 ❑Window(s) www.minnehahacreek.ora Overall Pro'ect Descri tion: •�oa 0 • Estimated Construction Valuation of P�oject exCluding land $ `� � D� . � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by#he Building Depa�tment; . Certifies that the information supplied is true and cor�ect 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 reject it until it is complete; • Some or all of the information that you are asked to provide 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. Confidantial data is information whtch generally cannot be given to either the public or the subject of the data. Our purpose and intended use ofi this information is to a ually update our records and records of other governmental agencies re uired b law. If ou refuse to su the informatio .the a lication ma not be issued. Annlir-ant'c�innati ira• \ 11 � \ _ n�+o� i��Il9 I I.l