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City of Orono 'Building Permit Appiication for Maintenance / I�eplacement I l�enovation (No structura! expansion. Only windows, doors, siding, re-roof, etc.) ��Q Mailing Addr�ss: I PErmit number: PO Box 66 Crystal 8ay, MN 55323-DD66 � bate received: � � � � St2et Address: I Received by' y� ; 2750 Kelley Parkway �,� �,�' qrono, MN 55356 � Plan review fee: �'�sxo�` II Toial Fee: Main: 952-249-4600 Fax: 952-249-4616 www ci orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplefie ap�lications will be returned. ( /ease prinf) GENERAL INFORMATION: �� " � Job Site Address: Will this be a Parade o#Homes, emodelers S wcase Home or other Display Home? Yes No !/yes,a special evenr permit is required with Police Depsrtmenf and Ciry Council approval fi0 days priorto the event. Shuttle�us service wi/l he requrred unless epplicant demonstrates su�cient on-site parkinc�is avflilab/e, Non-permrtted evenfs wil!nof be allowed, CONTRACTOR/ P L! T INF MATI�N: Name: G� �~�-�.1y'1 � State License# Expiration date: r Lead Certifcatian Number. � Expiration Date: � (for work on homes that were cons ru d pri !0 797 i D 1'hone; (celf) �� (office) �1 - ( � 4 � Mailing Address: � City: ZIP: Contact Person: Appficant is:• 'Contrac or / hiorrteowner �ci��ie oae) Email and/or Fax� PROPERTY OWN R INFORMATION: Name' �,�, a� � l�-� Phone(day): '�� 1 � (� Address� � CA �� City: ZfP: ��'1 � Email�nd/or Fax: PRQJECT INFORMATION: Overalf ra ect descri tion, Type of Project: Any earth movement mdy dlso require � �oor(s) ❑RemodF� ❑ Fire Damage MCWD review 8�permits: Minnehaha CrEok Watershed DistriCt(MCWp) i ❑Re-roof,asphalt []Repair ❑Storm Damage tig20Z Minnetonka Blvd I ❑Re-roof, cedar ❑ Restoration ❑Water Damage peephaver,, MN 55391 `�Re-roof,o her{spscly) ❑Siding ❑Other�(specify) Phone; 95z-479-0590 � Fax: 952-471-0682 ❑Window(5) I wv✓w.minnehahacreek.or Estimated Construction Valuation of ProJect(excluding land) $ APPLfCANT ACKNOWLEDGEMENT: I . Agrees to provide all informati�n required or requested by the BuiEding Department; I � • Certifes Yhat the information supplied ls true and cprreCt to the best Of his/her knowledge. The applicant recognizes that they a�e solely responsible for submitting a Complete applicaYion being aware that upon faifuro to do so, the staff has no alternative but to reject i[until it i$Compfete; . Some or all of the information ihat you are asked to providE on this applicatlon is GI355ified by State law as either privatE or Conftdential. Pfivate d3t�is information which generally cannot be given to the publie but can be given to the subject of the data. Confidential data is information which generaily cannot be g�ven to eitfter t11e public or the subject of the daia. Our purpose 2nd � intended use of this nfor io �s to ally u ate our records and records of other governmental agencies requlred by law. If ou refuse to su I he f r h a lica n ia not be issued. Applicant's Signatur Dafe: �- l� Owner's Signature: Date: � — �'�' Lasi Jpdated:03l06/2013