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. i C�tyv �f Orono Building Permit Application for fi�aintenance / R��lacerment / Renovatian (No structural expansion. Only windows, doors, sidir�g, re-roof, e .) O Mailing Address: Permit number.�Q� � ` � ��'�-_, PO Box 66 , Crystal Bay. MN 55323-0066 � Date received: � ; � , �� Street Address i �eceived by: t �:' 2750 Kelley Parkway Plan review fee: `.��.i�+'�\,�`,� Orono, MN 55356 — � si�� , ) _ � Total Fee: /��. Main 952-249-4600 Fax 952-249-4616 4 ,.^. ti u , �s � _ ____ --- -_ -------__ __ _-- - ---- - - --- — 1-his application form must b�.� cc;rnpleted in full and all required information mus; be submitted. Incomplete appfications wiEf be reiurned. (Please print) GCNERAIINFORMATION: , ' �� Jci� �ite Acfdress� <'��D�-� _��E'.Y_�.100 �_ ►'�.,_. �YUVl� s� S� V�iil tnis be a Parade of Homes, Remodelers Showca�� Honie c�cther Gisalay Hom?� [� Yes �No If yes, a spucial event permit is required with Police Department and City Council approval EO days p�ior to tne ✓cr,! ;hi�tlle bus .c�vic�will ti�� reryuired unless applir,ant demonstrates sufficient on-site parking is available I�bn��permitted events will not be allowed. CONTRACTOR/APPLICANT 1NFORMATION: Name State License# Expiration Date: --__ --- -____ . _ _ - -- -_--- ----___ -- __ __ __ ___ __ --- - - ___ Lead Certificatior� Number Er,piration Cate __ - -- - _ _ _ _- ---- - _ _ (for work on homcs that were constructed prior to f97d Phone (cell) (office) ----- --------- --- --------------- ---._ --- -- -- ---------- --- Mailing Address: City: ZIP __---- ---- ------ --- ___ _---------- _ ____ __ __ _ - - Contact Person: Appiicant is: Contractor / Hom�o��;ner �Cirde One� Email and/or Fax: ------- ----- ---�---- ----- PrZOPERTY OW1�6�R INFORMATION: i�lame __� �___�75.�� _ - -- _ ___ . -- --- Phone (day) S�-3��- ��7/9 �- �- - Ad�ress: �� _ _c, err.�r�c� ►�, Ci�y (�ro,1c� _ ZIP S�?S-6 _ __ � — -.� � - - - -- - -_ _ _. __ Email and/or Fax: _c�,�_z-c�_��__v_r-,�-h_,�_I�__c o�-Y+----_ PRO.IECT INFORMA?'ION: Overall �roject descrirtion:____ _ _ _ - - -__ _ � __- . _--�-- --- --_ _ ___---- --- --- Type of Project: Ai�y earth movement may also rec�uire i MCWD review&permits: � ❑ Door(s) ❑ Remodel ❑ Fire Damage i � Minnchah�� Creek Watershed District MCWD � � ��e-roof, asphaft i j i?�;�Ui: ❑ Storm Damage iii702 Minneton!<a Bivd ( ) � f-I Re-roof cedar [� Resioration [] Water Damage Uc�ephaven, MN 55391 ❑ Re-roof other(specifyj ❑ 5iding ❑ Other (spc:cif;�) Piione 95?-4�i1-Q590 i Fax 952-471-06u2 _ Window(s) ---- �-��; � t�_,� ,�,; ��, �-- _ __ _- -------------------- --------------- -- -- --- ----, Estimateci Construction Valuation of Project�exclud��ig la�id) $._�� D L � ��"v kPP�ICI�.P�l7 f�C��(NOV4if�.�DGEl1fEt�T: - - -- ___. __ _ _ _ __ _ ------ - - -_ ___ _- - _ _ . __ _ _ _-- • Agrcas to proviCe all inforrnatior requued r reyuested by the 6uild!n� f��artrnent, • Cei!iiies that thc; informatien s,applied �s tr�:e and co�rr�ct tu the best of I��siher knowledge. The applicGnt recognizes that they are solely responsible ier submitting a conip!ete application being aware that upon faiiure to do so, the staff has no altemative 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 privaie or confidential Private data is information which yenerally cannot be yiven to the public but can be given to the; subject of the data. Confidential data is information wnich nera�ly cannut be yiven to e;th�;r tlie public or the subject ot the data Our purpose and intended use of this informatien is nnually up �, o��r records and records oi other governmental agencies required by law If � you refuse to suppl�the inforr � e a,oplic on m�av nct be issued _ _ __ __ __ _ --- -- - ApplicanYs Signature: ____.___ _ C%ate �'�I�.�L��_ Owner's Signature: _ __ ________ . Date: _____ Last Updated:03/06/2013