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City of Orono Building Permit Application for Maintenance/ Replacement/ Remodel—Residenti�l ONLY (i.e.windows, doors, siding, re-roof, etc.-NO STRUCTURAL EXPANSION) ,�O A?O Mailing Address: pem�it number. o�0� ?�� f v Crystal Bay,MN 55323-0066 Date reoeived: —15 � StreetAddr+�ss: Received by: ._. y�, �� 2750 Kelley Parlcway �� y��fee: , t � Orono, MN 55356 1K SH04� Total Fee: Main: 952-248�600 Fax: 952-249-4616 www.ci.orono.mn.us This application forrn must be completed in full and ali required infortnation must be submitted. Incomplete applications wili be returned. (P/ease priirt) GENERAL INFORMATION: Job Site Address: � � t'�1n�/� �A'I� S ,M,I�/ 5.�3.1 � � Will this be a Parede of Homes, Remodelers Shov�ase Home or other Display Home? Yes o H yes,a speci�evev�t pem►�is required with Pdice Dep�tmeM and City Couna/approval 60 days prior to the event Shuttfe bus servi�wfll be required uMess applicar►t demonstrates sulficieM on-site parking is evai/ab/e. Non-pe�mitted everds w�71 not be alla�d. CONTRACTOR/APPLICANT INFORMATION: Name: �;�'✓//�' s'�jL�f�� State License# Expiration Date: Lead Certification Number. Expiration Date: (fbr work on homes that w�ere consbvci�ed prloi M 1978 Phone: (cell) 'rl S2- 2�/1� -7(o�y . (offioe) 9`S 2" �f y�- q '729 Mailing Address: Za� 6� C OTT/� � /� � C�tY� _.)cC.�Lsj o ZIP: �� 1 Contact Person: J�F�1/��v Si/�ti E� Applicant is: Contractor / meowner i�o�e� Email and/or Fax: K�✓�N F� �7A1V E1C►�ll�E�'Tt1r N�S� C a l� PROPERTY OWNER INFORMATION: Name: S%R�"E 1� �QoP►c r'-� I A1�,ES i/�I�/U7S cr �'1►NNE�'f� Phone(day): Cj'SZ- yNT�- q�2g Address: Zo 1 b S �o,t�c-��1� Av� city: F x c��s�a-- Z1P: SS 33� Email and/or Fax: K F,v,,u (� �T,e��k�qJ VES�1�t�iV i S . L o� PROJECT INFORAAATION: Overall 'ect descri tion: 12E R`� �Nd A7►oa I3L�oe-►�S• - ACF 6ACA�i i-� Type af Project: Any�Nh movemerrt may also require ❑Door(s) ❑Remodel ❑ Fire Damage MCWD review 8 pennits: ❑Re-roof,asphalt (a'f�epair ❑Stortn Damage Minnehaha Creek Watershed Disfict(MCWD) 15320 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 ❑Re-roof,other(spedty) ❑Siding ❑Other.(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Wndow(s) v�w�v.minnehahacreek.or,g Es�mated Construction Valuatfon of Project(excluding land) s APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all infortnation required or requested by the Building Department; • Cert'dies that the iMormation supplied is true and comect to the best of his/her knowledge. The applicaM rBc�gnizes that they are solely responsibte for submitting a complete application being aware that upon failure to do so,the staff has no attemative but to reject it un61 it is corr�lete; • Some or all of the infortnation that you are asked to provide on this application is dassified by State law as either private or conflderrtial. Private data is infom�ation which generally cannot be given to the public but can be given to the subject of the data. Confidential 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 iMormation is to annualy update our reoords and records of other govemmeMal agencies requined by law. If ou refuse to su th information the ication ma not be issued. ApplicanYs Signature: � Date: 3/�o��7 Owners Signature: Date: 3/� '� / 1"� Last Updated:January 2016