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.• � City ofi Orono Building Permit Appt�cation for Maintenance / Replacement I Remodel — Resider�tial ONIY (i.e. windav+is, doors, siding, re-roaf, etc.—NO STRtlCTURAL EXPANSI�N) /�— Ma�ling Address: Permit number: ��-'G�� C� �` �� / �Q�j PO Box 66 _ � 0 Crystal Bay,MN 55323-0066 Date recelved: �� � Rece�ved by: �� Sfreet Address: 1 y � 2750 Kelley Parkway Plan review fee: �� Orono,MN 55356 , C-� �� "�k�SHOF' I, Total Fee: Main: 952-249-460� Fax�. 952-249-4616 www.ci.orono.mn.us " This application form must be completed in€ull and all required information must be submitted. Incomplete applications will be returned. �Please print) GENERAL IIVFORMATIOAf: � ��_ ;�,,2�� `�--�- � Job Site Address: � ''�� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? [j Yes o !f yes.a spec�a!ever+t permii rs required wrth Po/ice Depa�iment and Crty Council approval 60 days prior to the event. Shuftle bus service wi!!be repuired un�'ess aAplicartt aemonstra[es sufficient on-srte parking is avaifable, N'on-permitfed events will not be alJowed. CdNTRACTOR�P�P,LI�.CkANT INFORMAT}QN��` � Name: �. (�'LCcS-1�n-� 'ti�.� � State L�cense# _ Z'�Z, � Expiration Date: ��3i 1 Lead Certification Number: ��{��--- �'Z�'�"�`�- Z Expiration Date: �--4 � � (for work on homes fhat were constructed prior to 79T8 _��j--�� Phone: (cell} (office) (�`7l Mailing Address: L � • ls:��.�' � '�" �j1 - City:, _ l�'G'�L_ Z��: `��'�1c�r Contact Person: �} s Applicant is: ontractor 1 Homeowner �CircleOne) Emai1 and/or Fax: �..0. `-�-�Ylr�b��tZt u�fl'`l� ��-� � ' �'�� PROPER7Y OWNER INFORMATION:�} � � Name: '�C�!1 4L-�` , z.. Phone(day): ' `"�7�" 7 Cv(� 1 �.� Z�� - c Address 1 Z.7�; 1��-• , City: "� ZIP: �J J� i 1 Email andlor Fax: PROJECT INFORMATION: Overall project description: _ Type of Project; Any earth movement may also require MCWD review 8 permits: ❑ Door{s) ❑Remodel ❑Fire Damage Minnehaha C�eek Watershed Disirict{MCWD) [-'j Re-roof,asphalt ❑ Repair ❑Storm Damage 15320 Minnetonka Blvd ❑ Re-roof,cedar � Restoration ❑Water Damage Minnetonka,MN 55345 Phone: 952-471-a580 ❑ Re-roof,other(specity) ❑ Siding ❑Other: (specity� Fax: 952-471-0682 �lYindow(s) �- �- '�'', . f .�i\�-` �j wwwmi�nehahacreek.orq Estirnated Constructian Valuation of Project(excluding land) $ � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required�r requested by the Building Department; • Certifies that the information supplied is true and correct to the best of hisfier knowledge. The applicant recognizes that they are solely responsible(or subm�tting a complete application being aware that upon failure to do so, lhe staff has no altemai'�ve bu;to reject it until it is complete; • Some or aIl of the information that you are asked to provide on this application is classified by State law as either psivate or confidential. Private data is informafion which generally cannok be given to the public but can be given to the subject of the data. Confidential data is inforrnation which generally cannot be given to either the public or the subject of lhe data. Our purp�se and intended use of this information is to annually update our records and records of other govemmental agencies required by law. lf ou refuse to su I the information,the a lication ma nol be issued. �__ i L� - 12. - l�1 Applicant's Signature: �— �� ` �� Date: Owner's Signature: Date: Last Updated;Jarvary 2C1 B _ Z'd 90��LSL 6S9 6ui�apouaa�saa�sew��ea�