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� � � City of Orono Building Permi# ApQlication for Maintenance ! Renovation {windows, doors, siding, re-roof, etc.j �"�� MaiJing l�ddress. D/ _ � ��-�7' PO Box 66 Permii number: 0 ,,� Q Cry�tal Bay, MN 55323-0066 Date received: 9�/D/?j �. �^ �- �f Streel Address: Received by: �'�' 4 o~F l 2750 Kefley Parkway ��r�s�o'¢� Orono,MN 55356 P�an review fee: _ 1 Main: 952-249-4600 Fax: 95�249-4616 www_ci.orono mn us Total Fee: � �Q�'�Q v p This ap plication f�rm m u s t b e c v m p l e t e d i n fu f l an d a l l required inforrnafion must be submitted. Incomplete apptications wfl! be retumed. (P/ease print) GENERAL lWFORMATION: Job Site Address� �a�j� .�(�,r�C�^�. �f,Q,�� Will this be a Parade of Nomes, Remodeler�Showcase Home or other Display Home? Yes No II yes,a specia/event permit is required with Aolice QeperFment and Ciry CouncN approva!60 days prior to the evenC Shuttle bus service wi!!be raquired unless appliCant demonstrates s'ufficient on-sife parking is availabfe. Non-pemritted events wi!!nof be a!lowed. CON7RACTOR/AP�P�L.ICANT INFORMATIO�V: Name: 0.� ,Av�,,�[,r�.� Staie License # �C,130�8� Lead Certification Number: Expiration Date: 7j� 3� N T- o? 0?83 - Expiration Date: � (for work on hornes that were constructed prior b 1978 Phone: (051� a -t��-}-�., (office) Mailing Address: � � ,�C„ �e� C' . (cefl) Contact Perso�: �'�StV�I e. Z�P� S�� "3 — Applicant is: ntractor / Homeowner �ci.ae o�o� Email and/or Fax: - PROPERTY OWNER INFORMATION: Name: S Phone (day): -' �, 1 �� Address: — 45 - - l► Email and/or Fax � �� C��'� Z1P: PROJECT INFORMATION: � Type of Project: Any earth movement may requlre �j Door{s) � ❑ Remodel MCWD review 8� ermits: ; ',(] Fire Damage Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, asphatt I ❑Repair � Storm Dama e 9 18202 Minnet�nka Blvd ❑ Re-rooi,cedar ❑ Restoration �Water Damage Deephaven, MN 55391 ❑Re-roof,other(apeclty) � � g�di�g Phone: 952-471-0590 ❑ Other: (specify) Fax: 952�71-0682 _��Window(s) www.minnahahacreeic orq Overall Project Description: I R�1ac� a w�o,�S (o d4x wl rrv • Estimated Constructron Valuation of Project�exciuding land ��Q � �� ) � o� 1 Q�J r APpLICANT ACKNOWLEDGEMENT: • Agrees 2o provide all inforrnation required or nequested by the euilding Department; � Certifies that the information supplied is true and correct to the best of hislher knowledge. The applicant reoognizes that lhey are solely responsible for submitting a complAte application being aware that upon failure to do so, the staff has no alternative twt to reject 'rt until ii is complete; ' • Some or ail of the information that you are asked to provide on this application is classified by State law as either privaie or I+ confidential. Private data is information which generally cannot be given to the public but Can be given to the subject of the data. Gonfidentlal data is information which generally cannot be given to either ifie public or the subject of the data. Our � purpose and intemded use of this information is to annually update our records and records of other governmental agencies re uired b law. If u refuse to su I the infdfmation, the a lication ma not be issued. Anoficant's Sianature:01, C�-� ��,3 Date: Z 'd 06T9�L9TS9 3�Ih�13S 1IW21�d Q B S f� LT �ET ETOZ Oi daS