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� � City of Orono Building Permit Application for Maintenance / Renovation {windows, doors, siding, re-roof, etc.) Mailing Address: a � l � �3S O�O.�O PO Box 66 Permit number: � Crystal Bay, MN 55323-0066 Date received: .� �, ,;� h StreetAddress: Received by: �'� �" ��' 2750 Ketley Parkway Plan review fee: {eg��' Orono, MN 55358 " Total Fee: �� 5 �j Main: 952-249-4600 Fex: 952-249-4616 www-ci.orono.rnn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. {P/ease printJ GENERAL INFORMATION: Job Site Address: �s ��(h�,p�,t�, y��(•� Will this be a Parade of Homes,Remodefers Showcase Home or other Display Home? ❑Yes No lfyes,a special eveni permit is rtrquired with Police Department and Clty Courtcil approva!60 days pnortn the event. ShutUe bus service will be required unless applicant demonsirates sufl7ceent on-site parking is available. Non-permifted events will not be aDowed. CONTRACTOR/APPLICANT INFORMATION: Name: 1�1rGr�,i,Ja.\ �'Ar�t<serJ State License# �C 1309$'3 Expiration Date: 3 f 3� Lead Certification Number: (�j�-�_ a� a$� _ � Expiration Date: +{f�e (for work vn homes that were constructed n.ler tn 1978 Phone: (p5�- a l04-�{Q$� (o�ce) (ce11) Mailing Address: l9 0'1 C . 1� '�C" WQ.S-4- C�tY="�,prS�V,11e Z�P� SSl 3 Contact Person: Applicant is: onVactor / Homeowner �c�i.o�.� Email and/or Fax: PROPERTY OWNER INFORMATION: Name; �c� ��( 'f'r�� Phone (day): 95�1- �� a�.D Add ress: �S�-}Cr City: 21 P: Email andlor Fax PROJECT INFORMATION: Type of Projeci. � My earth movement may require + ❑ Door(s) ❑ Remode! ❑ Fire Damage MCWD review 8 permits: I ❑ Re-roof, asphalt ❑ Re air Minnehaha Creek Watershed District(MCWD) p ❑Storm Darnage 18202 Mi�netonka Blvd ❑ R�roof, cedar Restora2ion Daephaven, MN 55391 ❑ ❑Water Damage ❑ Re-ro�f, other(apeciry) ❑Sidi phone: 952-471-0590 �g ❑Other: (specify} Fax: 952-471-0682 ❑Window(s) i www.minnehahacreek.orq Ove�all Project Description: p� � i � Estimated Construction Valuatio of Project (exc{uding land) $ S'+5s�/Q� APPLICANT ACKNOWLEDGEMENT: . Agrees to provide al4 information required or requested by the Building Department; • Certifies thai the infnrmation supplied is true and correct to the besi of his/her knowiedge. The applicant recognizes that they are solely responsible for submitting a complete apptication being aware that upon failure to do so, the staff has no alternati�e I but to reject ii until it is complete; � Some or all of the i�formation that you are asked to provide on this applicaUon is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public bui 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 informaaon is to annuafly update our records and records of other governmental agenaes re uired b law. If u refuse to su I the information,the a lication ma not he issued_ AneficanYs Sianature• Date: v �� � Z 'd 06T9�L9TS9 3�IA213S lIW�l3d Q '8 S f� BE �ST ETOZ BO �eW