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a . . � �� . � . `� City of Orono .� Buitding Permifi Application for Maintenance / Renovatio � (windows, doors, siding, re-roof, etc.) MailingAddress: Pertnit number: �� I O.�(�,�0 PO BoX 66 Crystal Bay,MN 55323-0066 Date reoeived: . � � •� i �� Received by: , � Sfrset Address: � 2750 Kelley Parkway Plan review fee: t��og�r ' Orono,MN 55356 �o��: oZ�� l5 Main: 952-249-4600 Fax: 952-249-4�616 www.cZ.or4no.mn.us � This application form must be completed in full and all requi�ed�information must be submitted. Incomplete applications will be returned. (Please print) � GEN�RA�INFORMATION�� . � Job Site Address: � Will this be a Parade of Homes,Remodelers Showcase Home o�otber Dispiay Home? Yes No ' If yes,a speciel everrf permit is required with Police Oepartment and City Council apprvve/80 deys prior ln Hte avent. Shutt�bus servjce will be requl�d unless applicant demonstrates su1`ilcient on-site parking Is available. Non permitted events will not be allowed. CONTRACTOR/APP CANT INFOR TION: Name: � yl )'Q � ' • State License# C� ,� 2 S � Expiration Date: -�/-j Lead Certification�Number: N�}T- (�'�CJ r - Expirdtion pate: 7 � � ��S � (for work on homas that were constructed prior to 1978 ,� , Phone: (o - 3) �- Q C'� (o�ice) (cell) � Mailirtg•Address; � •� Gi : � � ' •� ZIP: Contact Person: .�'� L ,S� Appllcant is: Cont / Homeowner �c�rcicone� Email and/or Fax: � (� jp,�.� -,3 ,S PROPERTY OWNER INFORMATION: � Name: ,�n ��(� � Phone da u C(� r ( Y)� r�la ��3��re7 T 5 � Address: � , e � - City: Z1P: Email and/or Fax PROJECT INFORMATtON: Type of Project: Any earth movement may require �Doo�(s) ❑ Remodel [a Fire Damage �CWD ceview�peRr+its: Minnehaha Creek Watershed Distriot(MCWD) Re-roof,asphalt ❑ Repair Storm Damage 18202 Minnetonka Blvd ❑ Re-roof,cedar Deephaven, MN 55391 ❑ Restoration ❑Water Damage � Phone: 952-471-0590 ❑ Re-roof,other(specify) ❑ Siding ❑Other. (speafy) Fa�c: 952-471-0682 �WindoW(s) www.t's'iinnghahacreek.ora Overall Projeot Description: �� - Estimated Constnaction Valuacian ot rro��a�t�excluding land) $ %, APPLICANT ACKNOWLEDGEMENT: . /�qrees to provide all information required or requested by the Building Department; . CeR�es th2t the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submiiting a complete application being aware that upon failure to do so, the staff has no alt�maifve but to reject it until it is complete; • Some o� all of the information that you are asked to provide on this application is dassified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subjed of the data. ConfidenUal datai is infarmation which generally cannot be given to either the public or the subject ofi the data. Our purpose and intended use of " inf ation is to annually update our records and records of other governmental agencies re uired b law. If u refuse u inf tion,the a lication ma not be issued. Applicant's Signature: Date: ' �'�� � i..�,i�..a,.��a. no ne�n�a '