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,. Oct. 4, 2011 3. 58PM No, 8124 P. 1 �, , ,� City of Orono Building Permit Application for Maintenance I Renovation (windows, daors, siding, re-roof, etc.) ..-_-�-__ MailingAddress: Pe►mitnumber: o.��/�-- U� O:�O,�O PO Box 66 Crystal Bay, MN 55323-0066 Date received; � ' �, Street Address: Received by: i�� � 2750 Kelley Parkway Plan revie e: ��< ' �° Orono,MN 55356 `.:qkEgslo�`'% =___= Totel Fee. —7 Main: 952-249-4600 Fax: 952-249�616 www.ci.orono.mn.us � / i This application form must be completed in full and all required information must be submitted. Incomplete appllcations will be retumed. (Please print) GENERAL INFORMATION: _ Job Site Address: `� � �' S L"'�-�w�:�� T R Wlll thls be a Parade of Homes,Remodelers Showcase Home or othe�Dlsplay Home? Yes o If ye9,a special event perrnit is required with Police Department and City Council appiova160 days pnor to the event. Shutt/e bus service will be requ;ied unless applicant demonstretes suHicient on-site parking is availabls. Non-permitted events win not be a/lawed. CONTRACTOR/APPLICANT INFORMATION: Name: S �_h �,�, �0�:� State License# z�y z � � 3 � y Expiration Date: �.��3 � ��,��_ Lead Certification Number. _N f} �1 .- ��3 �S-1 Expiration Date: (}p�ryoMc on homes that were consf►ucted prior to 1978 Phane: �JS�? - 7 �- � (office) (Cell) Mailing Address; � '7 � / E X � e �:.� �1) v ,4 � City: ��;y, Z�P= SS.�� 3 Contact Person: ('��,� � Applicant is� Contractor / Homeowner �ci�ia o�a� Email andlor Fax; 10,�.�"„��,� � S�n d �., s �� PR�PERTY OWNER IN�ORMATION: Name: �- � �\ a-� c K� Phone(day): �ya -� �:� _ �b� Address: y rl `1 � C•..�.�y�.,�.q Z nc.-�� _ City: OR,c�.�, ZIP:_^5.5 3S ^ Email and/or Fax PROJECT(NFORMATION: _�„M„ 1�Ipe of Project: '� My ealth movement may require MCWD revlew 8 pecmlffi: ❑Door(s) ❑Remodel ❑Fire Damage Minnehaha Creak Watershed District(MCWD) ❑ Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven,MN 55381 ❑ Re-roof, cedar ❑ Restofatlon ❑Water Ddmage Phone: 952-471-0590 []Re-roof,other�apeclty) ❑Siding ❑ Other:(speciry) Fax; 852�71-0682 �4lVindow(s) www.minnehahacreek.ora Overall ProJect Description: ��_ 1 � � � w � -�o _ .y s��- IZ �� ,v��A...,. Estlmated Construction Valuatlon of Project(excluding land) S ' �_� APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Building DepartmenY, • Certifies that the informalion supplied is true and correct to the best of his/her knowledge, The applicant recognizes that they are solely responsible f�or submitting a complete application being aware that upon failure to do so, the staff has no altamative 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 information which generally cannot be given to the public but can be given to the suhject of the dsla. Confidential data is inforrnation 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 records of other governmental agencies re uired b law. If ou r�efuse to su I the information the a lication ma not be issued. Applicant's Signature: c.:J�-�� _ � Date: � �''�-'�