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City of Orono � Building Permit Application for Maintenance / Renovation �' (windows, doors, siding, re-roof, etc. ) / :-O Mailing Address Permit number. � U � --� �%Q� �0\` COrysBtalXBay, MN 55323-0066 Date received: �� , �,j — ` _ �i; Street Address: Received by: \��'�t , ' °f� ��;� 2750 Kelley Parkway Plan review fee: '�.�'��c�Hot��% Orono, MN 55356 1 Totai Fee: �� / G7J Main: 952-249-4600 Fax: 952-249-4616 , . � E�u � �- .,... .... ___,-_, This apptication form must be completed in full and al! required information must be submitted. Incomplete appliGationa will be returned. (Please print) GENERAL INFORMATION: Job Site Address: 3�{n 7 Ca S-F- ��K e S�- or o,�o ,k,��J s 53 s� Wfll this be a Parade of Homea, Remodelers 3howcase Home or other Display Home? Yes No H yes,a speas/event permrt is reaurrad wrth Polrce Depertment and City Counci!approval 6p days pnor to the event. Shuttle bus service will be required unless applicant demonsirates suffiGent on-site parking is available. Non-permitted events wilf nol be a!low�d. CONTRACTOR 1 APPLICANT INFORMATI�N: Name: �A�eh s�rure-es �tilc, State License# �� s-e�G�� Expiration Date: �� _��_ ao�� Lead Certiflcation Number. N,�T, �o�-(g4 3- l Expirati�n Date: 0 3 _ ��_ �o r� ^ (lsnr work on homes that were construcied prior to 19T8 .� G,5_ a��_��S 8 Phone� "1�3-�ai-l7a-� (office) ,�+� �� (celq Mailing Address: 1 30 ��.c�.q ti,A,J S-� City: q �va(C„4 ZIP: S-s 30 Co�tact Person: �7 b � S�x Applicant is: ontractor . / Homeowner �ci�.a,.� Email and/or Fax: ��S•4 X� g�q�QrSetwiePSrNc.� �w� �.Q�c 7�� - r-la�—Z6 3 3 PROPERTY OWNER INFORMATION: Name: �'�I�ecC,a i-t�lze►v� Phone (day): �ra-f3o�-��10 Address: 3�r�'-1 �- �Ke S�__ Ciry: ot-o�.io �U� ZIP, SS�S�o Email and/or Fax � -- —�"- - PROJECT INFORMATION: Type of ProJect: Any earth movement may naquire ❑ Door{s) ❑ Remodel ❑ Fire Damage MCWD review 3 permits: Minnehaha Creek Watershed District(MCWD) ,� Re-roof, asphait ❑Repair ❑Storm Damage 18202 Minnetonka B1vd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re-roof, other(specity) ❑Siding ❑Other.(speafy) Fax: 952-471-0682 ��r,^n�n i r �a , ��: ❑Window(s) - -_. _.. Chrerall Project DeaceipUon: Estimated Constniction Valuatlon of ProJect(excluding land) _ � b o d APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all informa6on required or requested by the Building Department; • Certifies that the information suppGed is true and correct to the best of his/her knowledge. The applicant rccognizes that they are solely responsible for submitting a camplete application being aware that upon failure to do so, the staff has no attemative but to reject it until it is complete; • Some or all ot the information that you are asked to provide on this appliration is dassified by State law as either pnvate or confidenUal. Private data is infoRna6on which generally cannot be given to the public but can be given to the subjed of the data. Confidential data is infortnation which generally cannot be given to either the public or the subjed of the data. Our purpose and intended use of this information is to annually update our records and recorcJs of other govemmental egenaes re uired b law. If ou refu to su I the in ormation,the a lication ma not be issue�i. � ApplicanYs Signature: �� Date: //- 0 7-< ( Last Updated: 08-09-2011