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� S��P��23/201b/r RI 10� ?8 ?.'��` Elder Jones Bui lding FA� N�, 95? 854 7°C� P, G02 �ity o� �rono Building Permit Application far Maintenance / Replacemenfi! Remodel �- Residen�pal �NLY (i.e, wirtdows, doors, siding, re�roof, etc. � NO STRUCTURAL EXPANSlON} �O A T Mailing Address: � ��/�Q � �Vr-� PO Box 66 Permit numbsr. v u Crystel Bay, MN 55323-00$6 Qate recefved: � Stroet Addres5: Received by: y 2750 Kelle Parkwa `� �� Orono, MN 55356 y Pfan revfew fee: ��Fs�o�� i 9a�� Total Fes: Maln: 952-249-4600 Fax: 952�249-4616 www.ci.orono.mn.us This application form must be completed in full and all required inforrrtatlon must be submitted. Incomplete applications wlll b�returned. (Please prini) G�NERAL INFORMA710N:�� G � �� n �� Job Site Address: �) a �,�J Wfll this be a Parade of Homes, Remodelers Showcase Home or other plsplay Home? Yes No !f yes,a spsc/a!ovent permlt!s requlred wifh Pofrce Depaiiment and Clty Councll approval 60 days prior to the evsnt. Shutfle bus service w:!!bs required unless applicant demonstrates sufftclent on-site parking is availabls. Non-psrmlfted events wil!nat be allowsd. CONTRACTORlAPPL1CANT INFQR,MATION: Name: State License# ^ PeI1a Northlaz�d Expiration Date: Lead certi�ication Numl XS300 25th A,ve N. Ste 200 � �xpiration oate: {for work on f�om�s f� P�}��aouth, MN 55447 `"— Phone: (ce Lic#�BC645090 P11. 7G3/7�5-1400 (oTfice) Mailing Address: zIP' Contact Person: Applicant • Contractor / Homeowner (Clrcle Onc) Em�il andlor Fax: n�Sj � �� PROPERTY OWNER(NFC?RM,ATION: Name: � Phone(day): � 4 . � b Address: � / l� a t C ,�l City; � On �Q�G zIP: s'�'3 5'L Email and/or Fax: PROJECT INFORMATI�N: Overall project descriptic�n: Type of Project: Any earth movement may also reguire ❑ Door(s} ❑Ramodel Q Fire Damage MCWD review&permits: ❑ Re-roof,asphalt ❑ Repair ❑Storm Damaqe Minnehaha Creek Watershed pistrict(MCWD) 0 Re-roof,cedar 15320 Minnetonka Blvd � Restoratian ❑Water Damac�e Minnetonka, MN 55345 (�Re-roof,othar{specify} []Siding �� ❑�ther:(speoify) Phone: 952�71-059a ( r5') Fax: 952-47'(-0682 �Window{s�� www.minnehahacreek.ora Estimated Construction Valuation of Project (excEuding land) $ O l. ApPLICANT ACKNOWLEDGEMENT; • Agrees to provide all information required or requested by the Building Deparfinent; . Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that fhey are solely responsible for submitting a complete apnficatlon being awaro that upon failure to do so, the staff has no aiternative But ta reject[t until it is compl�te; � 5ome or all of the information tl�at you are asked to providE on this application Is classified by State law as either private or confidential. Private data is informa4ion whlch generally cannot be given to the public but can be given to the subJect of the data. Confidential data is information which c�enerally cannot bo given to either the public or the subj�ct of the data. Our purpos� and (nfended use of this information is to annuafly update our records and records of other governmenta!agencies required by law. If ou refuse to su I the informatlon,the ap lication ma not be issued. ApplicanYs Slgnature: �'r�--� bate: '� � / �' Qwner's SEgnature; C]ate: �ast Updated:January 2016