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� '' City of Orono � �� : t Building Permit Application for Maintenance / Renovafion �� (windows, doors, sidin re-roof etc. � j 9� � ) � ; j O Mailing Address: Permit number: p�/�–O� 7 �` �}� / y_ � CrysBtal Bay, MN 55323-0066 Date received: �� Z /j� � ,� i � i. �' �� U��'�:�, s, ' Streef Address: Received by: � �� . �� t' '��, �ti 2750 Kelley Parkway Plan review fee: � ` =' �`�gESHo�''� Orono, MN 55356 � — � � � � r � 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) �� �i� GENERAL INFORMATION: �� # i Job Site Address: /�j.S' �„�; ��j �,q-,�,�� ,�: z Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � ❑ No If yes,a speciaf event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service wiU be w� required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed. �� z` j� CONTRACTOR/APPLICANT INFORM TION: � . Name: / C.LS'�R� L"��uS�a��-;o�-, - State License# .�.��3 /s?� Expiration Date: 3 3 i ��— +� `` Lead Certification Number: � �$R�_ � Expiration Date: -7,-�, �,�— � � : (for work on homes fhat were constructed prior to ?978 � Phone: � � �-� �7�03- ��`3 - �'7�� (office) cell � Mailing Address: �� `N o�,z�� S' City: , �,ti ZIP: ,�3 g-� Contact Person: '� �o N� Appficant is: ontract / Homeowner (Circle One) � Email and/or Fax: �, PROPERTY OWNER INFORMATION:� Name: � Phone (day): Address: 1 D p �„�,pc.:-�/ G,q�,•� City: ��j,,, ,�;� ZIP: � ' Email and/or Fax �. b PROJECT INFORMATION: �� Type of Project: Any earth movement may require � ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: � Minnehaha Creek Watershed District(MCWD) � �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd � ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 '� ( p y) ❑ Sidin Phone: 952-471-0590 `� ❑ Re-roof, other s ecif g ❑ Other: s eci '"�� � P fY) Fax: 952-471-0682 ,,,� www.minnehahacreek orq ❑Window(s) k� �> ,� �;;: Overall Project Description: � �,y4yL p�'F _ ��vo CC Estimated Construction Valuation of Project(excluding land) $ /a (O� • � `'[� � APPLICANT ACKNOWLEDGEMENT: �� • Agrees to provide all informafion required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they � are solely responsible for submitting a complete appfication being aware that upon failure to do so, the staff has no alternafive �� but to reject it until it is complete; ;� • Some or al( of the information that you are asked to provide on this application is classified 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 subject of the '�� data. Confidenfial 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 information is to annually update our records and records of other governmental agencies .; re uired b law. If ou ref I the inf rmation, the a lication ma not be issued. � l �� � ApplicanYs Signature: - Date: �� 'Z f� K;.� Last Updated: 08-09-2011 �� �, ' : .,.:.. k � <, . .a �