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' ' ` �f ba Ci of Orono � Building Permit Application for Maintenance / Replacement / Remodel (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) Mailing Address: Permit number. 0�� 0 � ��O^IO PO Box 66 /_ ; Crystal Bay,MN 55323-0066 Date received: �" � � Stieet Addiess: Received by- ti� � 2750 Kelley ParkwaY Plan review fee: t " Orono, MN 55356 �'�f S N OR� Total Fee: � $, Main: 952-249-4600 Fa�c: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be r+etumed. (P/ease print) GENERAL INFORMATION• y� �1 � � � Job Site Address: � �'�L� Li v�v�y>1�h t'f v �,�lJ�7'7..c.�f'zt 1�'l I� �� �11 this be a Parade of Homes,Remodelers howcase Home or other Display Home? Yes No H yes,a speciat event permd is required wiTh Polioe Department and City Council approva160 days priw to the event. Shuttle bus service will be required uNess appl�icant derr+onshates sut�cient on-site parldng is available. Non-permitted events wiVt not be altowed. CONTRACTOR/APPUCANT INFORMATION: Name: Tbw� La��.�.v►� C'�.sr�►M ��5 1Qes-�odo��l�4 L.�.� State�icense# (�C �6 C��I Expiration Dat : 3 I 3 i 2016 6 � Lead Certfication Number: N q T- f !'-t�d U 3� �� Expiration Date: �,�v Z�, Zc�jq (for work on homes U►at wene consbucted prior to 1978 Phone: (cell) �l S 2- - y''l`� (o�e) cl.s Z't�$''{'d `'l`'t 9 Mailing Address: ' '1 � � ,� iu N�V,�.�,,,J ZIP: 6. Contact Person: T�,,,,i �F �(�Q ,�,1,, Applicant is: Contractor / Homeowner �c�cie o�e� Email and/or Fax: -f- L u f c(,,c v„� r� r1�1 C!f S""' C 0 v"1 PROPERTY OWNER INFORMATION: Name: � J.�e r y I � c'e.c f✓1 Phone(day): �►5'2� 3�3' /Z'I� Address: C"��`'� S�r wi.4 C h �c ti,e Cdy: I�'lo�z�,� l"(1� ZIP: Jr S �6 �( Email and/or Fa�c: PRWECT INFORMATION: Overall ro ect descri tion: R �a�e U er �u+ca��Qtr Vaov �� ,lr a:d D�c k C�� r/�o�y� Type of Project: My earth movement may also require �Door(s) ❑Remodel ❑Fire Damage ��w��: ❑Re-roof,asphalt �Repair ❑Stom�Damage Nbnnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(speciy) ❑Siding ❑Other(specify) Phone: 952-471-0590 Fax_ 952�71-0682 ❑Window(s} www.minnehahacreek.orp Estimated Construction Valuation of Project(excluding land) S 7 ��G•�� APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building DepartrnenY, • Certifies that the information supplied is true and corred to the best of his/her knoMAedge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is dassified by State law as either private or oonfidential. Private data is information which generally cannot be given to the public but pn be giv�en to the subjed of ihe 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 information is to an�ually update our records and records of other govemmental agencies required by law. If ou refuse to su I the infom►ation,the a lication ma not be issued. ApplicanYs Signature: Date: �� -s�2 01� / �/� Owner's Signature: Date: � �4�/O--/.� Last Updated:January 2015