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� � City of Orono � � Building PeRnit Application for Maintenance/ Replacement/Remodel-Residential ONLY � (i.e. windows, doors, siding, re-roof, etc. -NO STRUCTURAL EXPANSION) ' �O�O Mailing Addiass: �_ PO Box 68 Permit number. �_('`�� __ ) f Crystal Bay,MN 55323-0066 Date received: �=� -�7 '� � �, � Street Addiess: Received by_ � ' ''� `: 2750 Kelley Pa�tcway Plan review fee: l�kfSH00.E Orono,MN 55356 Main: 952-249-4600 Fax 952-249-4616 www.ci.orono.mn.us TotalFee: /� (� 3L/ 1 1(/ ( This application form must be completed in full and all required irNormation must be submitted. Incomplete appllcations will be retumed. (Please print) GENERAL INFORMATION: Job Site Address: �� 5� ` ,E'/ L' �(/�� (/ s��y� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No 11 yea,a speda!eve�n permlt!s�equrred wlth Police Departrr�ent and Crty Council approva�60 da required untess applicant demonstrates sul�icient on-site parking is available. Non ��e evenL Shuttle Dus seMce wd!be �ermifted events wil!not be adowed. CONTRACTOR/APPLICANT INFOg�ATION: Name: ,gR�}�c/� /�'Er?lc��/EG//1! � � State License# � ��r p Expiration Date: 3 �j �{jj Lead Certification Number. -� _ /I'�%�T— 3� i y� '.� Expiration Date: .�/a�/�o a O (for work on homes tfrat were constructed prior to l978 �T Phone: _(�}----------..�.._,_ (office) ( ��)��ib '�02��'� Mailing Address: / !J �,�/, � ,�.�.�; #a0.5� City; $1nc/run -ti�N ZIP: �� 2D Contact Person: j-;� ,�pW�/ • Applicant is: Contracior Homeowner �d�ae o�,e� Email and/or Fax: �,Lr�d�u�i a��nr�;�is"a/t�vi �l✓��Ptr Co/Yl • /.2��"3��.� PROPERTY OWNER INFORMATION: Name: O,f3C�T G!/�kO��sfC/ Phone(day): �' /�l �d � ��_ Address: �Qy �!/�i C �f/G /v CitY� (J/e0/�O ZIP: ,�.�39� Email and/or Fax: PROJECT INFORMATION: Overall ro"ect description: � LA�iN �v l�ljNdp�d t� `c�c,��j^/� pPPN�/Y9S Type of Project: �y e�mo��u� ❑ Door(s) ❑Remodel ❑Fire Damage MC��Pa+n'��: ❑ Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(M(,yyp) ❑ Re-roof,cedar ❑Restoration ��Minnetonka Blvd ❑Water Damage Minnetonka,MN 55345 ❑ Re-roof,other(specif� ❑Siding ❑Other.(specify) PhOne: 952-d71-0590 IJ Window(s) Fa�c 952�71-0682 www.minnehahaaeelc orv Estimated Construction Valuation of Project(excluding land) ; ,OCJ APPLICANT ACKNOWLEOGEMENT: � • Agrees to provide all information required or requested by the Buifding pepartrnent; ' • Certifies that the information supplfed is true and correct to the best of his/her knovuiedge, The app�i�nt recp9�f�s�t�y are i solely responsible for submitting a complete application being aware that upo�failure to do so,the staff has rro altunabve but to i rejecf it until it is complete; � • Some or all of the informatlon that you are asked to provide on this appliption is dassified by gts�e Iaw as eilher�� a � ., confiden6al. Private data is information which generally cannot be given to the p�Wic but can be 9iven��the date. Confidential data is information which generally cannot be given to Nther the public a the subjed ot fhe data Our purpa�e and intended use of this informa6on is to annually update our records and records of ofher govemmental ayencies tc�quitcd by�aw_ If ou refuse to su I the i a o the lication ma not be issued. / / � ApplicanYs Signature: Date: � �v Owner's Signature: Date: Last Updated:January 2016 +� . N