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NOV-10-2011 08:05 From: 6785736615 To:9522494616 Page:1�1 t � City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mar'ling Address: Permit number. c��//-�/ 7 O�,�,�0 PO Box 66 Crystal Bay, MN 55323-0066 Date received: / - /D - � � a, Str�etAddress: Received by: ��' 2750 Kelley Parkway Plan review fee� �y��.xo¢O Orono, MN 55356 � Total Fee: �D 5. O� Main: 952-249�600 Fax; 952-Z49-4616 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 printJ GENERAL INFORMATION: �, Job Site Address: � dQ,r'vi� Will this be a Parade of Homes, Remodelers Showcas� Home or other Display Home? ❑Yes o lf yes,a special event permit is requtred with Police Department and City Council approval 60 days prior to the event. Shuttle bus s ice wi/l be requfred unless applicant demonstrates su�clent on-site park/ng is available. Non-permitted events w/ll nof be ellawed. CONTRACTOR/APPLICANT INFORMA710N: Name: �$ ,�vw�n �6�u�rL.�� State License# �q��,�_�( Expiration Date: y f�� Lead Ce�ification Number: Expiration Date: � (for work on homes that were constructed prfor to 1975 Phone: ��- '�oD� (office) (cell) Mailing Address: �` �;,P„� ��6 �.�,�_ City: �� ZIP: 5�33 � Contact Person: ,�J .��,�� Applicant is: on �ct� / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: Gl�,r`rs G✓�'�L J'n 7 Phone (day): �� _ 3g��.8�� ' Address: qg D C� �,�M ��. City: Ql�r� ZIP: S'"'s' 3,S'� Email and/ar Fax ' -' PROJECT tNFORMATION: Typ�of Project: Any earth movement may requlre ❑ Door(s) ❑ Remodel ❑ Fir Damage MCWD review 8 p�rmits: Minnehaha Creek Watershed District(MCWD) [�e-roof,asphalt ❑Repair Storm Damage 18202 Minnetonka Blvd � ❑Watsr pamage Deephaven, MN 55391 ❑ Re-roofi, cedar estoration Phone� 952-471-0590 ❑ Re-roof, other(specity) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek ora Overall ProJect Description: Estimated Construction Valuation of P�oject(excluding land) $ / , 3 APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicent recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altsrna6ve but to reject it until it is camplete; • Some or all of the information th�t 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 giveh to the subject of the data. Confid�ntial daia is Information 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 and records of other gov�rnmental agencies re uired b law. If ou refuse to s . I th�informati the a lication ma not be issued. Annliranf'eCinn�+��ro l _\ � 1� � r�,.i... f� / �U J�