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OCT-31-2011 13:46 From: 6785736615 To:9522494616 Pa9e:1�1 R � � = City of Orono Building Permit Applic�tion for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Addr�s : Parmit number Og,O�O PO Box BB Crystal Bay, MN 56�23-0066 Date reoeived: � � ' �, StreetAddress. Received by: ��' 2750 Kelle Parkway Plan review fee: � Orono,MN 55356 k�H� Total Fee; �p�� (� Main� 952-249-4600 Fax� 952-249- 61B www.ci.orono,mn.us This application form must be compl ed in full and all required information must be submitted. Incomplete applic tions will be�eturned. (Please printJ G�NERAL INFORMATION: Job Site Address: � �S rc �VU`, l \�2. Wil!this be a Parade of Homes, Remodelers Sh wcase Home or other Oisplay Home? Yes �No K yes,a speciel event permit is required with Police Departmenf and City Council appraval BO days prior to the event. Shuttle bus seivfce will be �quired un/ess appllcent demonstretes su�cie�t on-site parfcing is available. Non-permitted events wi/l not be allowed. CONTRACTOR/APPLICANT INFORMATIOId: Name: �w ��,� '� State License# 5�31� Expiratio� Date: �j �Z Lead Certification Number: Expiration Date: (fer wor1�on homes that were constructed prior to 1978 Phone: (�. $6, �vv (o�ce) {cell) Mailing Address: �2 6(� �vp,- �2i �itY� v� Z�P: �'�33� Contact Person: ��, Applicant is: ont�acto / Homeowner (Circle One) Email and/or Fax: PROPERIY OWNER INFORMATION: Name: �, � � ^ Q Phone(day): q S Z- �j`3- I 3`Z Address: �'��' Cl,w•��-t, . � � ra�••a ZIP: $� S 3 S� Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review& permits: ❑ Door(s} ❑ Remod�l ❑ ire Damage � nehaha Creek Watershed District(MCWD) [�e-roof,asphalt ❑ Repai� torm Damage 18202 Minnetonka Blvd ❑Re-�oof, cedar [�'F�estoration ❑ ater Damage Deephaven,MN 55391 Phone: 952-471-0590 ❑ Re-roof, other(specify) ❑ Siding ❑ ther.(specify) Fax: 952-471-0682 ❑Window(sj www.minnehahacreek,ora Overall Pro'ect Description: � _v � - �� Estimated Construction Valuation of Project(ex'luding land) � a 7 . � APPLICANT AGKNOWLEDGEMENT: • Agrees to provide all informetion 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 recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative bu2 to reject it until it is oomplete; . • SomB or all of the information that you are ask d to provide on this application is classified by State law as either private or confidential, Private data is information which generally cannot ba given to the public but can be given to the subject of the date. Confidential data is information which ge�erally cannot be given to either the public or the subject of tha data. Our purpose and intended use of this information is Ito annually update our records and records of other governmental agencies re uired b Isw. If ou refuse to s I the infor ation,the a lication ma not be issued, Annlinon4'c Qinn�4i i�n� \ ..l � .. n-r-, �R'1 /� � /�/ �