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�i�y af Oror�o ' ` Buifding Permit Appi�ca�io� for Maintenance / Renovatio� (windows, doors, siding, re-roof, etc.) Mailing Address: i Permit number. �� 2 �D ��0,� PO Box 66 i Q �, � Crystal Bay, MN 55323-0066 i Date received: � '��' v.�,. 1� I�� . � Street Address: �Received by: � �� ,ti 2750 Kelley Parkway Plan review f : 9'kESH�� Orono, MN 55356 � TotalFee: /�, D� Main: 952-249-4600 Fax: 952-249-4616 wwv,�.ci.orono.mn.us This appfication form must be completed in full and all required information must be submitted. Incompfete appfications wili be returned. (Please print) GENERAL INFORMATION: Job Site Address: �'., (,! C k c �v�L :� ��ll -� Will this be a Parade of Homes, Remodefers Showcase Home or other Display Home? ❑ Yes ❑ No !f yes, a specra/event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service will be required unless app(icant demonstrates sufiicienf on-site parking is available. Non-permitted events wil/not be allowed. CONTRACTOR/APPLICANT INFORMATIOI�: Name: f z �'- i _ �Y _ State License # �� ,.;��j j 7�� Expiration Date: U `�j� Lead Certificafion Number: � Expiration Qate: (for work on homes that were construcfed prior fo 1978 Phone: f� Z 3�2 7� y�� (office) (cell) Maifing Address: Cit : ZIP: S '' 7�`U �/��f✓� T 3�.3c �� l Y l,ti/.��j/-��.� � ..)�/ � Contact Person: �T�1�^� F��,��.. Applicant is: �Contractor / Homeowner (CircleQne) Errzail and/or Fax: � �— Ni��;f 2fvi f�„i c� '��/c�-7r�-��;L .c Gn� PROPERTY OWNER INFORMATION: Name: (,L�/� �S'rl�"/Y�F�I � Phone(day): �(�/Z ) �� ; �3 3 ' Address: �S� C�,�/:S i/i�w v5�✓l-c City: �;,�,� l�/,Q,-�� ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: � � Any earth movement may require ❑ Door(s) ❑ Remodel ❑ Fire Qamage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvo ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 i � Phone: 952-471-0590 ❑ Re-roof, other(specity) ❑ Siding ❑ Other: (specify) i Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Overall Project Description: Esfimated Construction Vafuation of Project (exciuding land) $ ,d��r "" APPLICANT ACKN�W�EDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information suppiied is true and correct to the best of his/her knowledge. The appficant recognizes that they � are solely responsible for submitting a compiete applicaiion being aware that upon failure to do so, the staff has no alternative but to reject it unfil it is complete; • Some or all of the informafion that you are asked to provide on this appiication is cfassified by State law as either priva'te or confideniial. Private data is information which gene�ally cannot be given to the pub(ic but can be given to the 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 informafion is to annualfy update our records and records of other governmental agencies re uired b law. If ou refuse to suppl ;the inrormation,the a fication ma not be issued. �-''�;l ApplicanYs Signature: ��'' Date: __��/`/�Z Lzst Updated: OS-09-2011 ! �`