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To: Page 2 of 3' 2014-11-20 18:25:53(GMT) 16514004483 From: Revamp Remodeling&Design City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) s Mailing Address_ c t, 5l. c^ f/ 4 PO Box 66 Permit number: v J�> ICrystal Bay,MN 55323-0066 Date received: //-20 19 i ) Received b : Street Address: Y e. 4 2750 Kelley Parkway Plan review fee: c`' Orono, MN. 55356 ',2,1kEs HIJ� / „ 47 Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us !!C' • This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: . Job Site Address: 4'j' i C)0 . 1 On S Will thisbe a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes 7 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 unless applicant demonstrates sufficient nn-,site parking is available. Non-permitted events will not be allowed. CONTRACTOR 1 APPLICANT INFORMATION: Name: f.) r .� r'- �f.tfC�.}`N•d� t"'�cr t'�1fr. ��r i)r;' '. I�',S(0)1, _._ State License# A2_;,( (r,'1q-( e5 c.. U �1Expiration Date: :2,1'.,,i/7,---5 Lead Certification Number: N tI n 12i`(.p(`7..1 Expiration Date: (for work on homes that were constructod prior to 9978 Phone: (cell) 62/2-1359-to2C/q (office) Mailing Address: • d' • ) "`" c •• n / ! amp City:57-a— U). y - ZIP: -" —( .3., Contact Person: (R-Vv, Applicant is: infractor) 1 Homeowner (IC (Circle One) _ Email and/or Fax: ` lpeancao--, — — J PROPERTY OWNER INFORMATION: Name: C.(kIrleL 1 I Phone(day): 6151-- --41 ' Address; City:. ZIP: Email and/or Fax: PROJECT INFORMATION: Overall project description:* e ' ;s�1ti�l.- Iviryii;tt) _�'L ;kip) 0) I .£;Q)f'i- ,"ato IA: Type of Project: 1 . , (Any earth movement may also regjtire. t i) ❑Door(s) ❑ Remodel ❑Fire Damage MCWD review&permits: O)C' T2 ❑Re-roof,asphalt Li Repair El Storm Damage Minnehaha Greek Watershed District(MCWD) E]Re roof,cedar ❑Restoration 18202 Minnetonka Blvd ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(specify) ElSiding LI Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 0-Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ 1-cor APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; ucaiLI rnamei Icnowleage. I ne 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 you refuse to supply theinf rmation,the applj_ tion ma_not be issued. Applicants Signature:: t' l.0/V"l— 'f- L ('--..�` � Date: I dd... i ( /2 /j, r - Owner's Signature: Date: Last Updated::03/06/2013