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� r ' City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Malling Address: Permit number. O�,�,�.0 PO Box 66 Crystal Bay,MN 55323-0066 Date received: Street Address: Received by: � �ti`� 2750 Kelley Parkway P�an review fee: '�g�Ho�.g+ Orono,MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: � O � Job Site Address: Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No If yes,a special event perrnit is requiried with Police Department and City Council approva160 days prior to the event Shuttie bus se ice will be required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPL,�CANT INFO TION• Name: �iin� r�. nrt M o'i State License# 9'� Expiration Date: '� �Z Lead Certification Number. /�f "�"' (j_ Expiration Date: 6 � Phone: 6 f 2— �.-'jODt'j (office) (cell) Mailing Address: Z�j b 6 ;v�i : • C�tY� �S V�►� Z�P: $�$�3 3 Contact Person: ;�,�. ,"„� Applicant is: nt actor / Homeowner �ci.�i.o�a� Email and/or Fax: ,�v;,,� � PROPERTY OWNER INFORMATION: , Name: f��G��,-C� �t?�J� �� Phone(day): / Address: ��b .�- e,,�,,,� � City: �riO ZIP: �3,j�b Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review 8� rmits: ❑Door(s) ❑Remodei ❑Fire Damage Minnehaha Creek WatershedD(str(ct(MCW�) ❑Re-roof,asphalt ❑Repair �Stonn Damage 18202 Minnetonka Bivd �(Re-roof,cedar �Restoration ❑Water Damage �eephaven,MN 55391 Pho�e: 952-471-0590 ❑Re-roof,other(specffy) ❑Siding ❑Other:(specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Overall Project Descriptfon: !.v �,n �''�'� OM.1 LY� _Estimated Construction Valuation of Project(excluding land) S _�-(� DOO APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of h(slher knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no aitemative but to reject it until it is comp{ete; • Some or ail of the information that you are asked to provide an tliis application is dassifled by State law as either private or confidentiai. Private data is informaUon which generaily cannot be given to the public but can be given to the subject of the data. Confidential data is information which generatly cannot be given to either tfie public or the subject of the data. Our purpose and intended use of fhis information is to annually update our recvrds and records of other govemmental agencies r uired b law. If ou refuse to su I the fnformation,the a tication ma not be issued. ApplicanYs Signature: Date: �Z � �� Last Updated: 08-09-2011