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i • City of 4rono Buiiding Permit Application for Maintenance/Repiacement/Remodel — Residential ONLY {i.e. kvinciovvs, c�c�c�rs, sic�i�€�, r�-roz�f, �#c. -- N�} S-["FtJ�TURt`-,� EXPAI��#Uf�!} O Mailing Address: Permit number: � C�/ j � �O PO Box 66 � � Crystal Bay, MN 55323-0066 Date received: � Street Address: Received by: l� y � 2750 Kelley Park�vay Plan review fee: ••—" `�t � Orono, MN 55356 ��SjjO�� Total Fee: jl2 . � � Main: 952-249-46Q0 Fax: 952-249-4616 ��nrw ci orono mn us This application form must be completed in full and all required information must be submitted. Incomplete appifcations wiil be returned. (Please print) `�y�s� ��`�j��,E'� 0%� GENERAL INFORMATION: �I� Job Site Address: �2�"7 L� u� 4- F �c,;� ' Will thls be a Parade of Homes, Remodelers Showcase Home or other Dtsplay Home? Yes No N yes,a special event permit rs required wifh Police Department and City Council approval 60 days prior to the event. Shuttle bus service witl be requrred unless applicant demonstrates sufficient on-site parking is availabte. Non-permitted events will not be atlowed. CONTRACTOR/APPLtCANT INFORMATION: Name: VV i PC: !-�Uv�-Q� State License# (�� - Z�p�y�2 Expiration Date: ,3��;1 Z p� 7 Lead Certification Number: N�'� Expiration Date: N �� (for work on homes that we�e consfructed p�1or to 7978 Phone: (cell) (,�I 2 - 3� (�, - (p?2� (office) Mailing Address: !�2; tJ arrn cu-�d C,a.s�, City: �.��„{�;,� �`,ZIP: 5�3�-{�,�- Contact Person: (-�� l I ►�o h l.�,v� Applicant is: ontra / Homeowner {Cl�cle One) Email and/or Fax: b ; l l C W� p o ln c��..Q��. r�c�rv� PROPERTY OWNER INFURMATION: Name: p Gl.v� � t�l-E',i l SSU.. �v ct��zeru Phone(daY): �Ia 2 - �L3a ~ �R�t� Address: �"I� Nvni- F�Lvf�� 1� c� ��tY� �vu;�a ZIP: '�-r352,� Email and/or Fax: ry�.�,l i SSC� �r�,,�..1�C•-' (�YvtC�.i 1 . c" c�� _ J�C ''�Ct�-c' / 'Cc tiC �Cl <SL �'f�/�/C��P � �:,�i'�?�LJ PROJECT INFORMATION: Overall ro'ect descri tion: � /" �� Type of Project: Any earth movement may also requlre � Door(s) ❑ Remodel ❑ Fire Damage MCWD revlew&permlts: ��Z� ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) �-�,�- 15320 Minnetonka Blvd G ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof,other(specit� ❑Siding ❑ Other:(specify) Phone: 952-471-0590 � / �� Fax: 952-471-0682 ❑Window(s) wµnv,mii�nehahacreek_orq �� Estlmated Construction Valuation of Project(exctuding land} $ � 3r.�Z'3!� APP�IGANT ACKNOW�EDGEMENT: . Agrees to provide all information required or requested by the Building Department; . Certifies that the information supplied is Vue 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 staff has no altemabve but to reject it until it is complete; + Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Privete data is information which generally cannot be given to the public but can be given to the subject of the data. Confiden6al data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this inform 'on is to annually update our recards and records of other governmental agencies required by law. If ou refuse to su I the i orma' the a lication ma not be issued. App(icanYs Signature: Date: ��Z� �j l.p Owner's Signature: Date: Last Updated:January 2016