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DE�•/?4/2016/WED 02; �9 PM Elder Jones Building FAX No, 952 854 4909 P. 002 City of Orono Building Permit ApplOcati�n fior Ma�ntenance / Replacement/ Remode! �- Resld�ntial ONI.Y (i.e. windows, doors, siding, re-roof, etc. --NO S7RUC7URA,L �XPANSION) �� ` O Mailing Address: Parmit number: l C^1 - ; ( �, '`• ��Y PO Sox 66 Crystal Bay, MN 55323�0066 I�ate received_ j �I � I�s Str�et Address: Raceived by: � �'�� �y�, ti� 2750 Kelley Parkway Pfan revlew fse: — ' � �' Orono,MN 55356 ��H�Maln; 952-249-4600 Fex: 952-249-4616 www.ci.orono.mn.us Totel Fee: ( �� I �� This application form must be completed ir�full and all required informati�n must be subrnitted. Incomplete appllcatlons wi11 be returned. (Please print) GENERAL INFOaMATION: �� ,� _/� / Job Site Address: 4 � Q � G r� �,n Will this 6e a Parade of Homes, Remodelers Showcase Home or other Dlsplay Home? Yes ❑ No /f yes,a special avant permi�is required with Police Department and City Council approval 60 days pBor ro tha event. Shutt�e bus service wil!be requrred un�ess applicant demonshates sufficient on-sife parking!s avallabls. Non-permiited eventa wi!!nof be allowed. CONTRACTOR!APPLICAN7 IN�bRIVIA"fION: Name: State License# Pella Notrt�Zland Expiration Date: Lead Certification Numbc 15300 25t�Z,A,ve N. Ste �00 �xpiration Date: (for work on homes th� ,[��n011111, MN SS�Q�� Phone: (celf Lic#�CG4509p�1�. 763/745-1400 °tfice) 9 sa��S •`d y7 �p�� Mailing Address� City: ZIP� Contact f'erson; Applicant is� Contract , / Homeowner �cir��ohey Email and/or Fax; PRpP�RTY OWN�R INFORMATIO�: Nams: �/+7 Q � �/� G Pf�one(day): 4 !� � a • �� Address: (, S a � � ciry� (,J p 7 a�� : 5 5 ',.! j ! Email and/or Fax: PROJECT INFORMATION: Overa�l ro'ect descrip#ion: Type of Prqject: Any earth movemant may alSo requlre ❑Door(s) ❑Remodel ❑ Fire Damage MCWQ revlew 8�permits: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 1532D Minnetonka Blvd ❑Re-roof,cedar ❑Restoratfon ❑W&ter Damage Minnetonka,MN 55345 ❑Re-roof,other(epecisy) ❑S1ding ❑Other (specify) Phone' 952�71-0590 Fax: 952-471-Q682 '�Window(s) www.minnehah�cresk.orc3 Estimated Construction Valuatfon of Project(excluding land) $ APP�ICANT ACKNQWLEDGEMENT: • Agrees to provide all information requirscf or requested by the Bullding Department; . Certifies that the information Supplied is true and correct to the best oF hislher knowledge. The applicant recognizes that they are solely respottslble for subrnitting a complete application being aware that upon failure tq da so,the staff has no alternative but to reject ii until it is complete; . Some or e)� of the information that you are asked fo provide on this appllcatlon is classifled by State law as either private or confidential. Private data is information which generally cannot be given to the publie but ean be glven to the subject of fhe data. Confidential data is informatlon whleh genarally eannot be given to eifher the public or the subject of the data. Our purpose and fntended use of this information is to annually update our records and reCords of other governmental agenCfes required by law_ If ou refuse to su I the Informati the a Ilcatlon ma not be issued. Applicant's Signature: �'I Date� !'� r� �� L Owner's Signature: Date: Last Updated:January 2096