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! , � �� vp7 � City of Orono �uilding Permit Application far Maintenance i Renovatian (windows, doors, siding, re-roof, etc,) � lviailing Address� o2D l � —O D S' ; �, ,��z PO Box 66 Permit number: -� Crystal Bay, MN 55323-0066 Date received: 9 �,3 / oZ �, 0 ��`�; '`ta ,,�'t�� 1, Received by: � �i Street Address� �`:1��, �� Gti;�� 2750 Kelley ParkwaY Pian review fe ��r�kES�i�n�'�''� Orono, MN 55356 ___ ,.=- Tota l Fee: p� p� �. a � Main: 952-249-4600 Fax: 952-249-4616 wunv.ci.or�n�.rr�n.us This application form must be completed in full and all required infarmation must be submitted. incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: isao ro:� sc�eec, ti�:��c� r�r; s�3°a1 Wiil this be a Parade of Homes, Remodelers Showcase Home or other Oisplay Home? ❑ Yes � No /f yes,a special event permit is required with Pofice Department and City Councit appraval 60 days pnor to the evenf. Shuttle bus service tiiilf be required unless applicant demonstrates sufficient on-srte parking is availat�le. Non-permitted events rvill not be allowed. CONTRACTOR t APP�ICANT INF�RMATIUN: N8(11@: lind-Nelson Construction Inc State License# BC36a6ao Expiration Date: 313�rz0�3 Lead Certification Number. R-i-�Bsia-�a-ooaaa Expiration Date: 2�2si2o�5 (far work on homes that were consiructed prior fa t 978 P h0118: 612-282-3006 (office J 612-282-3006 (C611) _�_ ..__... . M2111t19 AdC1f8SS: 3794 299th Ave NW Cit : Isanti Z�P; 55040-5956 Contact Person: �eff Neison Applicant is: Contractor J Homeowner �c�r�ie one� Email atldlOf F2x: jnelson�iindnelson.com PROPERTY OWNER INF(�RMATION: Name: conley srooks Jr Ph0�2(d2y�: 952-473-7354 Address: tsa0 Pox Street City: wayzata ZIP: 55391 Email andlar Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s} ❑ Rernodel ❑ Fire Damage MCWD review 8�permits: Minnehaha Creek Watershed District(MCWD) � Re-roof,asphait ❑ Repair ❑Storm Oamage 18202 Minnetonka Bivd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-059� ❑ Re-roof,other(specify) ❑ Siding ❑Other. (specify} Fax: 952-471-0682 ❑Window(s) wv�w.rnie�nehah�rreek_�rq O�erall Pro}ect Descriptio�: Tear otr&rep�ace aspna�t roarir,g Estimated Construction Valuation of Project(excluding land) $ �2,000.00 APPLICANT ACKNOWLEDGEMENT: • Agrees to provide aii information required or requested by the Building Department; • Certifies that the information suppiied is true and correct to the best of hislher knowiedge. The appiicant recognizes that they are solely responsibie for submitting a compiete application being aware that upon failure to do so, the staff has no aiternative but to reject it until it is compiete; • Some or all pf the information that you ara asked to provide on this applicatian is classified by State law as either private or confidentiai. Private data is information which generaily can�ot 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 pubiic or the subject of the data. Our purpose and intended use of this info�mafion is to annually update our recnrds and records of other governmental agencies re uired b law. If ou refuse to su I the information.the a lication ma not be issued. Applicant's Signature: �--� Date: sit3��2 Last Updated: 08-09-2011