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City of Orono Building Permit Application for Maintenance / Replacement i Renovatio� (No structural expansion. Only windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: �,(�J1 j PO Sox 66 � Crystal Bay,MN 55323-0066 Date received; Received by: Street Address �' ,� 2750 Kelley Parkway Plan review tee: y� c? Orono,MN 55356 Iq'CESNO�� Tota1 Fee: Main: 952-249-4600 Fax: 952-249-4616 www ci.orono.mn.us This application form must be completed in full and a!I required information must be submitted. Incomplete appticatlons will be returned. {Please print) GENERAL INFORMATION: � �de D�c v� ,�� JP.c Job 31te Address: o`Z 7��2 ��Yy S v-'�-- — Wilf this be a Parade of Homes, Remodefers Sho case Home or other Dlsplay Home? Yes No !f yes,a speclal evenl permrt rs required with Pofice Department and Crty Councif approva!60 days prior to the evenl. Shuttle bus se ice wifl be required unless applicant demonstrates su�cienf on-srte parking is availabfe. IVon-permitted events will not be allowed. CONTRACTORlAPP CA TINFORMA710N: Name: C��Y-e-1� {�'O�. l.�-YV� Cd State License# (p� Expiration Date: Lead Certification Number: �"�a(p�(jS-1 Expiration Date: f (for work on iromes that were constructed prior fo 1978 Phone: (cell) (o�ice) 5a-v�7� ' (o Mailing Address: �� Ce Sia V � Cit : ZIP: Contact Person: � vt }��lNiO Applicant is: C�ntracto / Homeowner �ci.�ie o�.j Email andlor Fax: .� (,°, . CD�Yt PROPERTY OWNER INPORM TION• . Name: �l,V� l D Phone(day): •b � ZIP: Address: e �/Q City: V71(/J p rJ' Email and/or Fax: PROJECT INFORMATION: 4verall �o'ect descri tion: Type of Project• Any earth movement may a�so requlre ' MCWD review&pertrzits: �Door(s) ❑ Remodel ❑Fire Damage i Minnehaha Creek Watershed District(MCWD) ❑Re-roof,asphatt ❑ Repair ❑Storm Damage 1g202 Minnetonka B1vd ❑Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 F'hone: 952-d71-0590 ❑Re-roof,other(spsclfy) ❑Siding ❑Other: (specify) Fax: 952-471-0682 ❑Window{s) www.minnehahacresk.ora Estimated Construction Valuation of Project(excluding land} S APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Depa�tment; • Certifles 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 but to reject it until it is complete; • Some or all of the information that you are asked to provide on ihis application is ciassified 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 tha subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and recor8s of other governmental agencieS required by law. If ou refuse to su I the information,the a licatiop ma not be issued. ApplicanYs Signature: �d Date: �«' Owner's Signature: Date: Last Updated:03/06l2013