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♦ City of Orono Buiiding Permit Application for Maintenance / Replacement / Renovation (No structural expansion. 4nly windows, doors, siding, re-roof, etc.) MailingAddress: Permit number: a� �3��l� � Cry sal Bay, MN 55323-0066 Date received: /0 '� -�3 Street Address: Received by: ` ;, �" 2750 Kelley Parkway Plan review fee: • �'t L� Orono,MN 55356 �,Z `!7Q(,�� '�'��sNo�`�` TotaEFee: �9$, �D � Main� 952-249-4600 Fax: 952-249-4616 www ci.orono.mn.us l"his application form must be completed in fuil and all required information must be submitted. Incomplete apptications will be returned. (Please print} GENERAL INFORMATION��D �D� �a�� OQ „p Job Site Address; �t Wiil this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes .�No !f yes,a specia!event permil is requi2d with Police DepaNment a�td Crty Council approva160 days priorto the evenf. Shuttle bus service will be required unless appllcanl demonstrates sulficient on-site parking is available. Non-permitted events will not be alfowed. CQNTRACTOR/APPLICANT INFORM ION: Name: ��.{� S . State License# ��Qj 3(pg Expiration Date: f �q= Lead Certification Number: �f�_ �(p�Q�r-'-/ Expiration Date: 0.23 /S (for work on homes thaf were constructed prior to 19 8 Phone: (cell) (offce) 9J�a`0?7 -�(D �j� Mailing Address: d'�,�/ s��y City: ZIP: Q Contact Person: Z 5��y„� Applicant is: on r / Homeowner �ci«�e on�� Emai! and/or Fax: C �. ' �Y,�� . � PROPERTY OWNER I FORMATI N: Name: �GJ{�' S G{,/�Q�1 /l� Phone (day): , ;L Address: D � Q`'yy� OG� City: ��, ��!(.Q ZIP: 5jr�j�L Email andlor Fax: PROJECT INFORMATlON: Overall ro'ectdescri tion: Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑ Fire bamage MCWD review&pertnits: ❑ Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof, other(speclfy) ❑ Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-A71-0682 �Window(s) ��CCCS�YY1�Qt�tfS www.minnehahacreek.orq Estimated Constre�ction Valuation f Project(excluding land) $ 7 f�? �-X[�Sfl•n5 O�iYk�s. APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Depariment; • 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 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 private or confidential. Private data is intormation which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which qenerally cannot be given to either the public or the subject of the data. Our purpose and intended use of fhis information is to annually update our records and records ot other govemmental agencies required by law. If ou refuse to su I t inform tion, lication ma not be issued. t •ApplicanYs Signature: Date: d ��- �� Owner's Signature: Date: last Updated:03/06/2013