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To: Page 2 of 3 20'13-06-'13"16:4�J'S6 (GMT) From_ Apex Encr�y Solutions City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) �/��A k� Marlrng Address Permit number; � �- (�"D (� 1 V PO Box 68 � Crystal Bay, MN 55323-0066 Date received: -� 3�� � � Sfreet Address: Received py: �, -� ,,. f Y `�f 2750 Kelley Parkway Plan review fee: � ��q�� µ�,� Orono,MN 55356 s t�i� Total Fe� �`�� Main: 952-249-4606 Fax: 952-249-4616 v_w�nn�.cLoro�c,.mn��Js " � -- This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (P/ease print) GENERAL INFORMATION: ... Job Site Address: ��'� �� 1�-�1�"h GjG� �'� Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home2 ❑Yes No !f yes,a specia!event pe�mrt is required with Po'ice DepaRment and City Counci!approval 60 days prror to the event. Shuttle bus service will be required unless applrcanf demonstrale5 su�cienf on�site parking is available. Non-permitted ever�ts wi!!not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: �1-�.cK �V��+;,{ .SLf(,t.��G'n-S State License# ��,��:i�(� �� k�V��-� Expiration Date: --- �ead Certification Number:—�-��}'T - 3j 3�t 3.--� F�cpira#ion Date: yr�,�.� Zp( .r,. (for work on homes that were constructed prior to 1978 T-�� Phone: (ceH) j�.S��l -5��-��-�'/3 i �� (office) Mailin Address: S�I'OC� � �a�—��-Fj%U ,:Su.i Ci -... _ 9 Nrrrv��w<< �l �. �1.2.L� �Y� ..Biavm�w�r'�,� z�a S�f31 Contact Person: C;,Lv`f� Cc l/�t r' � Applicant is: Contractor ! Homeowner (CircleOne) Emaii andlor Fax: �p��,(j��-r�y �y��,�� ,��,� --� ._.._ PROPERTY OWNER INFORMATlON: Name: ��i'r1 ,Sei --�R�' Phone{day): �'� -��- , '+�� Address: ��'(� 'V� 't-��_rtiGQ� � __._..._ CitY: (�'.��L`6'�0 ZIP: �JJ`��I Email andlor Fax: PROJECT INFORMATION: Overall pro�ect descri tion: 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) 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 Fte-roof,other s cI Phone: 952-471-0590 ❑ ( pe fy) ❑Siding ❑Other:(specify) Fvc: 952-471-0682 [�Window(s) dwo�n�minn�hahacrF��k Ofq Estimated Construc#ion Valuation of Project(excluding land) $ /�� . �� QPPLICANT 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 F�is/her knowledge The applicant recognizes that ihey 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 a11 of the information that you are asked to provide on this application is dassified by State law as either private or confidentiaL Private data is information which generaliy cannot be given to the public but can be given to the subject of the data. Confidantial data is information which g�nerally cannot 6e 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 govemmental agencies required by law. (f _�ou refuse to su I the information,the a lication ma not be issued. Applicant's Signature: Date: 4= /'�' �,.� Owner's Signature: Date: Last Updated:03/06I2013