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. • Cifiy of 4rono Building Permit Application for Maintenance I Replacement / Renovation (No structural expansior�. Only windows, doors, siding, re-roof, etc.) �O^} Ma11rPg�A�d X�6s�s- Permit number: �/�—f>/D r�� Crystal Bay,MN 55323-OQ66 t?ate received: ! — Street Address: Received by: -ern y �'' 2750 Kelley Parkway Plan review fee: `� � Orono, MN 55356 r�kESN�� Total Fee: � /a�.3� 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 mus#be submitted. lncomplete applications will be returned. (Please print) GENERAL iNFOl2MATION; Job Site Address: 5 � �Q �G�� Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No If yes,a specia!event permit is required with Police Department and City Counci!approva!&0 days prror to the event. Shutfle bu erviCe wi11 be required unless applicant demonstrates sulficient on-site parking is available. IVon-permrKed events wil!not be s!lowed. CONTRACTOR/APPLICANT INF�RMATION: Name: �,y� $ . (,l State License# a 3� ��q Expiration Date: 3 31 �0!� Lead Certificafion Number: �f�j, a(o3 QS�/ Expiration Date: � (ior tvork on homes that were constructed prlor to 1978 Phone: {cell} (office} S' -02 7�/6�j� MailingAddress: Q / �'Q SLd/' City: Gln $ Z1P: �- Contact Person: N��_S�y�pr Applicant is: n ract / Homeowner �c�reie o�e> Email and/or Fax: ^ ��'y� ay� __ �C� p{��/�jjs . C�'�`- PROPERTY OWNER fNFIORI�AATION: Name: �j t i I � �OCt/vl w1� �-Q- Phone (daY): a.- �(- (p7 � (,�.�2C�. Address: ^�SS" ,��,�.� `� �. City:.�� ZIP: rj`j3�1 1 Email and/or Fax: PROJEC7 INFORMA710N: Overall ro"ect descri tion: Fype of Project: Any earth movement may also require �:Doar(s) ❑Remodel ❑ Fire Damage MCWD revlew&permits: ❑Re-roof,asphait � Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD} 18202 Minnetonka Blvd ❑Re-roof, cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof, other{spectiy} ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora Estimated Constructlon Valuation of Project(excluding fand) $ 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 applicant recognizes that they are solely responsible{or 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 classifed by State law as either private or confdential. Private data is information which generally cannot be given to the public 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 fhe data. Our purpose and intended use of this information is to annualfy update our records and records of other governmental agencies required by law. If ou refuse to su I th information th I' t�on ma not be issued. Applicant's Signature: Date: 1! 0��3 Owner's Signature: Date: Last Updated:03l06/2013