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NOV-07-2011 14: 15 From: 6785736615 To:9522494616 Pa9e: 1�1 � C�ty of �rono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: Permit numbe�: :��'i/- �'� '� O.�Q �1�O PO Box 66 `w Crystal Bay, MN 55323-0066 Date received: �� Street Address.� Received by; - � ! � � 2750 Kelley Parkway Plan r'eview fee� t,,��o�i Orono, MN 55356 �—� ��C, Total Fee: ` � -� , �-J/ Mein; 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. Incomplete applications will be returned. (Please print) GENERAL INFORMA710N: /► / Job 5ite Address: f7 (_,�vt-Grx `�- Will this be a Parade of Homes, Remodelers Showcase Home or othe�Display Home? Yes ,� No If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the evenk Shuttle bus service will be required unless applicant demonstrstes sufficient on�ite parking is avallable, Non permitted events will not be allowed. CONTRACtOR/APPLICANT INFORMA710N: Name: � ,� �n. vr� C.�+� State License# �0 S9 . 6 S�a Expiration Date: 9 2 Lead Ce�tification Number; Expiration Date: (for work on homes th t were constructed prior to 1978 Phone: �/2 � $ j- 7ooe (office) (cell) Mailing Address: /�-�(o(o �� '�.� City; ��s�� ZIP: ;�5�� _ Contact Person: � � Applicant is: Contractor / Homeowner (Circle One� EmailandbrFax: �n� ,� S�r�,��,rc��e� �-e �.�-- PROPERTY OWNER INFOR ATION: � Name; �,.��+2 L✓o Phone (day): 9SZ- 7/� 7 Z8 / Address: d ,L �� City: „L� ZIP: S`�' 3 � Email and/or Fax PROJECT IN�ORMATION: Type of Project; Any earth movement may require MCWO�eview g permits: ❑Door(s) ❑ Remodel ❑ Fire Oamage Minnehaha Creek Watershed District(MCWD) .[+]�Re-roof, asphalt [�epair [�Storm Damage 18202 Minn�tonka Blvd Deephaven, MN 55391 ❑ Re-roof, cedar ❑ Restoration ❑Wat�r Damage Phone; 952-471-0590 ❑Re-roof,other(specify) [�Siding ❑ Other. (specify) Fax: 952-471-06$2 ❑Wndow(s) ' www•minnehahacreek.orq Overall Project Description: �"�✓-p�F � ��/D� Estimated Const�uction Valuation of Project texcluding land $ ! D - � 3 APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; . Certifies that the information supplied is true and wrrect to the best of his/her knowledge. The applicant recogn¢es 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 p�ovide on this application is classified by State law as either private or cnnfidential. Private data is information which generally cannot be given to the public but can be given to the subject of thg data, Confidential data is informaiion which generally cannot be given to either the public or the subjed of the data. Our purpose and intended use of this information is to annually update our records end records of other governmental agencies re uired b law. If ou refuse to u I the information,the a lication ma not be issued. . . ., ,. ., ... n G,l � �^�,.- �l/�� /� //