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. �� ; . ''� 'C�ty of Orono Building Permit App�lication for Nlaintenance I Renovation (window$, doors, siding, re-roof, etC.) �.G—� �=� Mailing A�dress: O � y_,�,�7. pp gk�c ss Permit number: -- � � Crys#!al Bay, MN 55323-Q066 Date received: - Q - �� a �'�,��-� �• Street Ad��ess: Received by: �� , E ��o o'� 2750'�ICelley Parkway ly �., Plan review fe � jc�Ho j �ronp; MN 55356 � �Main: 952-249�600 Fax: 952-`�49-4616 www ci.orono mn us Tobl Fee: 1/� 3 � � This application form must be co'�hpleted in full and all required information must be submitted. �ncomplete a�plications will be returned. (Please print) GENERAL 1NFORMATION: Job Slte Address: a� b� -e,�,�(' � � � �'� � 1 Will this be a Parade of Homes, Remodele 'Showcase Home or other Display Home? ❑Yes No !f yes,e specia!event permit is requrred with Police O�psrtment and Crty Council approva(60 da s required unless applicant demonstrates sll�cient on-sihe parking is avai/able. Non-permifted evsnts w7lrnof be�allp edervice wiU be CONTRAGTOR/APPLlCANT INFORMATIOtV: Name: 1�`�.W0.\ �y 'av�,CrSer� State License# �j�„�30�$� Expiration Date: '3�3S Lead Certification Number_ f�j�-j'r. a�. ''�' $3 - l Expiration Date: t�f�s (for work on homas that were constructed pri�r to 1g78 " — Phone: (DS y- o�(D -4��i�- (office) (cell) Maiting Address: (q a 0 C . '1� "C" WeS� Cit SS( 3 Y'�Scu:11C Z(P: Contact Person: ' Applicant is: ontractor / Home�wner �c;rcia o�� Email and/or Fax: PROPERTY OWNER INFORMATlON� Name: � � ' 'F'l �Q`f� 1 Phone (day): �Q\a.S� � Address: �� ' City: Z�p: Email andlor Fax PROJECT fNFORMATION: Type of Project: Any earth movemerrt ma r y equire � Door(s) 1�p� ❑ Remodel ,�Fire Oamage MCWD review 8 permits: ❑ Re-roof, asphalt ❑ Re �r Minnehaha Creek Watershed District(MCWD) Pa� ',Q Storm Damage 18202 Minnetonka Bfvd ❑ R�roof,cedar ❑ Restoration Dee ha�en, MN 55391 �� UVater Damage P ❑ Re-roof,other(apeciiy) � ❑ Siding Other. s Phone: 952�71-0590 'Q � Pe��tY) Fax: 952-47�-0682 �Window(s)CZ www.mmnehahacreek orp Overal I Project Description: �,', 2 �;�,��,� l C,�I;r� - Estimated Construction Valua2ion of Pro'ect � S� '� _ � �xclu�ing land) � f O4 , �y �p _ APPLlGANT ACKNOWLEDGEMENT: - Agrees to provide all inlormation required or r'epuested by the Building Department; • Certifies that the information supplied is true;and correct to the besi of his/her knowledge. The applicant rec�ognizes that they ane solely responsible for submitting a complete application being aware that upon failure to do so,ihe staffi has no alternative but to reject it unti!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 subject of the data. Confidential data is inforrnaiion which'j generally cannot be given to either the public or the subject of tfie data. Our purpose and intended use of this informatior� is to annually update our records and recorcis of other govemmental agencies re uired b law. If ou refuse to su I the in `rmation, the a lication ma not be issued. Ao�licant'sSionature: � �jt�� /O��/� �ate: � ! Z 'd 06i9�L9TS9 3�IA�13S lIW�l3d Q '8 S f� O� �bT ETOZ Ot daS