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. City of Orono Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) �O�O Mailing Address: �j� �—�� PO Box 66 RECEIVED Permit number: Crystal Bay, MN 55323-0066 Date received: �O "�— � � StreetAddress: ,,f�J{� O g �0�6 Received by: ti � 2750 Kelley Parkway Plan review fee: `�t L Oro o, MN 55356 qk£SH�� CITY OF ORONO Total Fee: av�� 3 Main: 952-249-4600 952-249-4616 www.ci.orono.mn.us This application f9� be completed in full and all required information must be submitted. `'� o plete applications will be returned. (P/ease print) GENERAL INFORMATIO� � Job Site Address: C(� -�. Will this be a Parade of omes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required uniess appiicant demonstrates sufficient on-si(e parking is availabie. Non-permitteo events wil!not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: � State License# Expiration Date: 3—3 j—/7 Lead Certification Number: �� 2,�(� —Z Expiration Date: (�� q�� Phone Work on� THD At- Home Service, Inc, offic O„S ] ( ��- �S Z 3 y S- � Mailing Addres: 2690 Cumberland Pkwy, Ste 300 Cit : zIP: Contact Person Atlanta, GA 30339-3913 Applicant i . Contractor Homeowner (Circle One) Email and/or F� Lic# CR268257 Ph. 763/542-8826 --- PROPERTY OWNER INFORMATION: Name: ��l�f'�Y� SG�U�'�Y Phone (day): (� L a S'� �V Z 3 Address: � City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall project description: /'� � , � 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 District(MCWD) 15320 Minnetonka Blvd ❑ Fte-roof,cedar ❑ Restoration ❑Vb'dier Damaga Minnetonka, MN 55345 ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 �-�Pdindow(s) www.minnehahacreek.ora Estimated Construction Valuation of Project(excluding land) $ - - 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 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 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 information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If ou refuse to su I the information,the a lication ma not be issued. Applicant's Sgnature� '� Date: � Owner's Signature: Date: Last Updated:January 2016