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� 4, City of Orono Building Permi# Applica#ion for Maintenance / Renovatian (windows, doors, siding, re-roof, etc.} /�O� Mailing Add�ss. �� PO Box 66 Perrn"rt number: ��/3 � � Q Crystal Bay, MN 55323-0066 Date r�eceived: �-o�-1–� �, , �.y ��l Sireet Addr�ss: Received by: '�'� ` 7 G� 275o Kelley Parkway �Ho�� Orono, MN 55356 Plan review fee: `-_�- Main: 952-249-460p Fax� 952-249-4616 www.ci.orono.mn us Total Fee: � �7v,7�� This application form must be compleied in full and all required information must be submitteci. Incomplete appfications wiU be returnQd. (Please prrnt) GENERAL INFORMATION: 1 ` Job Site Address: 3�+a o tv 1 � �h� Will this be a Parade of Homes, Remodelers owcase Home or other Display Home? Yes No If yes, a special event perm#is iequired with Police Department and City Counci!approva!60 days prior to the event. ShufUe bus service will bs requi�ed unless applicant demonstrates suflicient on-site pBrking is available. Non-permitted events wid not be aJ/owed. CONTRACTOR/APt�P{LICANT rNFORMATION: Name: 0.� � 'A -�rSe� State License# �C,��pq �I 3� Lead Certificatian Nurnber: $�� _ _ �Xpiration Date: N�?" a �'a`33 -1 Expiration Date: y��s (for work on homes that wore constructed prior b 1978 � — Phone: (05�_ a� _��-�,-� (office) Mailing Address: ,� „ (cell) 1 C . 1i c wes� c�ry:'�scv;► e zip: 5-St 3 Contact Person: Applicant is: oMractor / Homeowner Email and/or Fax: ��'��1 PROPERTY OWNER INFORMATION: Name: � � Phone{day}: , Address: �� Email and/or Fax � C��' Z�P= PROJECT INFORMATiON: Type of Project: Any earth movement may requiro ❑Door(s) ' ❑ Remodel ❑ Fira Damage N1CWD review 8, permits: ❑ Re-roof, asphalt Minnehaha Creek Watershed District(MCWD) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd Q Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-rovf, other(apeciiy) ❑ Siding ❑pther: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.or OverallProjectDescription: �� `i� Estlmated Construction Yaluation of Project(excluding land) � Q ' r- APP�ICANT ACKNOWLEDGEMENT: • Agrees to provide aIf information required or requested by the Building Department; • Certifies that the intormation supplied fs true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staf�has no alternative but to reject it untif it is complete; • 5ome or all of the information that you are asked to pro�ide on this applicatlon is classified by State law as either private or confidential. Private data is inFormation which generally cannot be given to ihe public but can be given to ihe subject of the data_ Confidential data is information which generally eannot be given t� either the pubfic 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 re uired b law. If ou refuse to su I the information, the a lication rna not be issued. AoalicanYs Sionature: �) n,.l�� Date: Z 'd 06T9bL9TS9 3�IA�13S lIW�l3d Q B S f� OT �Ei ETOZ iZ �+EW