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< `• City of Orono Building Permit Application for Maintenance / Replacement / Remodel (i.e. windows, doors, siding, re-roof, efic. — NO STRUCTURAL EXPANSION} ,�O�} MaiNP Box 66. Permit numbeT� �1�!S–��;e� 'VQ -`< - ;: Crystal Bay,MN 55323-0066 Date received.. 7-�_:f..s Streef Address: Received by, –"�'.�*��-� y ; i -- �, G�� 2750 Kelley Parkway Plan reXiesN fee: - l�'YESH04�' Orono,MN 55356 -_ - Total Fee."- `�c�. �, ; Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us _":_ _.. �___ � ..i,, This application form must be completed in fuil and all required information must be submitted. Incomplete applications will be returned. (Please prinf) GENERAL INFORMATION: � / Job Site Address: /0�5 L�!�de�� C,.�/'j� Will this be a Parade of Homes, Remodelers Showcase Home or other Dispiay Home? Yes No If yes,e speclal event permlt Is required with Pollce Department and Clty Councll approval 60 days prfor to the event. Shultle bus service will be required unless applicent demonstretes sulilclent on-site parking is avalla6le. Non�ennitted events will not be allowed. CONTRACTOR/APPLICANT INFOR TION: Name: ��/I�V'�-1� Y�0$. '�.U.N'�(p�l� State License# gG �39 369 Expiration Date: 3 3/ lb Lead Certification Number: ��(p�0 �� Expiration Date: �p� (for work on homes that were construcfed prlor to 1978 Phone: (cell) ,�j' � �— �$ (o�ice) Mailing Address: ,e($�..p r^ �/ City: / ZIP: Contact Person: h Applicant is: ontrac o Homeowner �cir�i.o�.� Email and/or Fax: G Y,,�, P,k�ir OS. �.0 PROPERTY OWNER INFORMATI Name: �a�a �.Y�SOVI Phone(day): �a, • O,(�- O,�a Address: /D�$ lyd,cn �f�.� City: (��O ZIP: �j 3(v� Email and/or Fax: � PROJECT INFORMATION: Overall ro'ect descri tion: Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: ❑Re-roof,asphalt ❑Repair ❑Stom�►Damage Minnehaha Creek Watershed District(MCWD) ❑Re-roof,cedar 18202 Minnetonka Blvd ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(specity) ❑Siding ❑pther($pecify� Phone: 952-471-0590 Fax: 952-471-0682 �Nindow(s) � �.minnehahacreek.ora Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all informallon required or requested by the Building Department; • Certifies that the information supplied is tnae and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete appiication being aware that upon failure to do so,the staff has no alternative but to rejed 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 conBdential. Private data is information which generaliy 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 lntended use of this information is to annually update our records and records of other govemmental agencies required by law. If ou refuse to su I th information the a licatiort�ma not be issued. Applicant's Signature: Date: �O Owner's Signature: Date: Last Updated:January 2015