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f . From: 06/21/2013 11 :06 #711 P.001/001 �-�; ,'�p�n�c l�} City of Orono Building Permit Application for Maintenance / Replacement I Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) �O�O Marlrng Address: Permit number: D — � PO Box 66 Crystal Bay,MN 55323-0066 Date received: �o�/ Street Address. Received by: � � 2750 Kelle Parkwa yF G. Y Y Plan review fee: �,� �, Orono,MN 55356 kFSH�� / _/.i/� Total Fee: iofo �f� 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. Incomplete applications will be returned. (Please prinf) GENERAL INFORMATION: ( � Job Site Address: �-r/ � �'�� '�� L- �� L_�'�G� Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No !f yes,a special event permR is required wifh Police Department and City Council approval 60 days prior to the event. Shuttle bus service wil!be required unless applicant demonstretes su�crent on-site parking is available. Non-permitted events wilf not be allowed. CONTRACTOR/APPLICANT INFORMATION: , f (� Name: � J D�5 U 1/�. I t vIn��cQ —�i�L• State License# G-- 3 S Expiration Date: � /S Lead Certification Number: Q- �- �p,��e{ _ � j- bOZ7 Expiration Date: /z (for work on homes ihat weie constructed prior to 1978 Phone: (cell) �ptZ-c��.-�p�� (office) (��I-�-{�o-3 Ya o Mailing Address: l d� S,��e6 f 2-� ��` S�t City: ��-��S ZIP: �j S�3 3 Contact Person: �� ,,,�.�. Applicant is: Contractor / Homeowner �c��i.o�e� Email and/or Fax: �rv�a,rw,� �&,a,�ce-�xtFr � c.r g . �� PROPERTY OWNER INFORMATION: Name: �h q�r �.� f� Phone(day): q S Z - �-gy_Z��c�. Address: (p� �"�,7 Sy,� � ( �r�t� r-��s City: ZIP: Email and/or Fax: PROJEC7 INFORMATION: Overall ro eci descri tion: Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑ Fire Damage MCWD review&permits: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed DisUict(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-<171-0682 �]Window(s) `��`7�- �'S�� www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ 2D�gsZ� APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Cehffies that the information supplied is true and correct to the best of his/her knowiedge. 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 inforrnation 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 subject of the data. Confidential data is information which gene Ily cannot be given to either the public or the subject of the data. Our purpose and intended use of this inform ion is to an all update our records and records of other governmental agencies required by law. If ou refuse to su I th rma i the a ication ma not be issued, ApplicanYs Signature: `�--Date: jO��Gl-1� Owner's Signature: T' Date: �� Last Updated:03/06/2013