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� �lug, 12. 2014 2; 03PM �'o. 0412 P, 1/1 <br /> � City of Orono <br /> Building Permit Application for Mainten�nce / Replacement / Renovatian <br /> (No structural expansion. Only windows, doars, �iding, re-roof, etc.� <br /> �n��, MallingAddress: Penmt numb�r��-�'���'� <br /> v PO Box 66 <br /> Crystal Bay, MN 553Z3 0066 [�afe re�e�ved __, • ° . ���� � <br /> Rec��uec�hy� � , <br /> St�eet Address; - . ' <br /> �.�, � 2750 Kelley Parkway Rd�n��VI�W fe� � <br /> t �G Orono,MN 55356 � ,,� <br /> �kEs�Io� '�o#al����� x <br /> Main: 952-249-46Q0 Fax: 952-249-4616 www.ci.orono,mn.us ,,:�, ``'� <br /> 7his application form must be completed in full and all required information must be submitted. <br /> Incomplete applications wifl be returned. (P/ease prinf) <br /> GENERAL INFORMA710N: <br /> Job 51te Address: " <br /> WIII this be a Parade of Homes, R�modef rs Showcase Home or other Display Home? Yes No <br /> lf yes,a speciel eVent pemlit is r�qulr6d wllh Po!(Ce Dapartmenf and City Council spproVe!60 days prlol'(o the event. 5huttle bus service will be <br /> required�mless app!lcenP demonsltales sufflcient on-site parking is svallable. Non-pe�mftfed euents will not be allowed. <br /> CONTRACTOR/APPLICAN7 INFORMF�yT10N: <br /> Name: C,�e.(.-.�i/' «�'��. V►'► �P�t' �� <br /> StaEe License# Expiration Date= ap/ <br /> Lead Certification Number: �- - �,�. � Expiration Date: <br /> (for work on homes that w re consbuctod prlor to 9978 <br /> Phone: (cell) �r '�"7 � f(p� (vffice) <br /> Mailing Address: O ,5 �,� � City: . �� zIP: '� � <br /> Contact Person: Q r� Applicant is: ontrac�or Homeowner (Clrcle One� <br /> Email andlor Fax; C JSmpV.P�������Ir�V`(�JYt�S•Gi1tn� _ <br /> PROP�RTY OWNER INFORMATION:. <br /> Name: e.Q.V1 � C LL, QV) �V1 <br /> Phone(day): � - •- <br /> Address; �.[� e City: . .�� p � ZIP: `j <br /> �mail and/or Fax: <br /> PROJECT INF�RMATIQN: Overall ro ect descri tion: <br /> Type oF Project: Any earth movement may also requlre <br /> � Door(s) ❑ Remodel ❑ Fire Damage MCWD revlew&pertnits: <br /> ❑ Re-roof,asphaIt ❑Rep�ir ❑ Stomi Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> 0 Re-roof, cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑ Re-roaf, other(speclfy) ❑5iding ❑Other: (specify) Phona: 952-471-0590 <br /> Fax: 952-a71-0682 <br /> �Window(s) Www.minnehahacreek.ora <br /> Est(mated Construction Valuat;on of Project(excluding land) $ <br /> ApPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide all information required or requesied by the Bulfding Department; <br /> • Cerfifies ihat the Information supplied is true and correct to the best of his/her knowleclge. 7he applicant racognizes that they are <br /> solely responsible for submltting a complete epplication being aware that upon fallure to do so, the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the informatfon that you are asked fo provide on this 2ppllcatlon ls classified by State law as either priv�te or <br /> confldenfial. Private data is information which generally cannot be�iven to the public but can be given to the subject of ihe data. <br /> Confidential data fs information which �enerally cannot be given to elther the public or the subject of the data. Our purpose and <br /> iniended use of this informatlon[s to annu�lly update our records and records of other governmental agencies required by law, If <br /> ou refuse io su I the�nformaiion, the a licatian ma not be issued. <br /> Applicant's Signature: �1� Date: c�� o�Q� <br /> Owne�s Signature: Date: <br /> Last Updated:03/06/2013 <br />