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Jun, 11. 2014 2; 19PM No. 8358 P, 1 <br /> � Gity of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, d�ors, siding, re-roof, etc.) <br /> q, Malqng Address: Permit number: 02 U � ��OS�'j' <br /> ��{VO PO Sox 66 <br /> Crystal Bay,MN 55323-0066 D2te receivsd: � ������ <br /> StreetAddress: Received by; �s <br /> y�, � 2750 Kelley Parkway Plan review fee: <br /> �'�RESH�4�4 Oronp,MN 55356 <br /> Totsl Fee: lg f,� <br /> Mairt: 952-249-4600 Fax; 952-249-d616 ww�v .,r�i:orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applicatlpns will bs raturned. (Please printJ <br /> GENERAL INFORMA710N: <br /> Job Site Address: 2425 Maple Lane <br /> Will this be a Parade of Homes, Remodelers 3howcase Home or other Display Nome? Yes No <br /> M yes,a special eveni permit fs required with Po!!ce Departmern and City Council approva!60 days prlor ro�he event. Shuttle dus s wi1!be <br /> requlred unless applicant demonstrates sul�«ent on-site parking is avaflab/e. Non-permftted events wip not be aAowed. <br /> CONTRACTOR 1 APPLICANT INFORMATION: <br /> Name: Superior Exteriors MN Inc. <br /> State License# scsas�2s Expiration �ate: 3/31/16 <br /> Lead Certification Number: NAT-126149-1 Expiration Date: 6/22/17 <br /> (Ror work on homes that were constn�cted prior!0 1978 � <br /> Phone: (cell) (office) <br /> Mailing Address: �j'� To�v�c�S c�ty: ziP: s.5�1 �5�{Z� <br /> Contact Person: 5,�,,,.� �� �, Applicant is: Contracto� ! Homeowner �c�«a o�a� <br /> Email andlor Fax� ��� <br /> PROPERTY OWNER INFORMATION: <br /> Name: bavid Rothstein <br /> Phone(day): s�zaea-aasa <br /> Address' 2425 Mapie Lane �Ity:Orono ZIP:55356 <br /> Email andlor Fax: <br /> PRQJECT INFORMATIdN: pverall pro'ect descri tion: <br /> Type of ProJect: Any earth movement may also requfre <br /> ❑Door(s) []Remodel ❑Fire Damage MCWD revlew 8�permits: <br /> Re-roof,asphaR Re a�r Minnehaha Creek Watershed District(MCWD) <br /> �i ❑ p � �Storm bamage <br /> 18202 Minnetonka Blvd <br /> �Re-roof,cedar ❑Restoratipn ❑Water Damage � Daephaven,MN 55391 <br /> ❑Re-roof,other(6peciry) �Siding ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0B82 <br /> ❑Window(s) www.minnehahacreek.or4 <br /> Estimated Construction Valuation of Project(excluding land) $9.��� <br /> APRLICANT ACKNOWLEDGEA�ENT: P��ASE CALL FOR CREDIT CARp PAYMENT 612-382-2549 <br /> • Agrees to provlde ell information requifed or requested by the Building Department; <br /> • Certifies that the information supplied is irue and correet to the best of his/her knowledge. The appflcant recognizes that thay are <br /> soleiy responslble for submitting a complete applicatian befng aware that upon faiiure to do so,the staff has no altemative but to <br /> reject it until it is complete; <br /> • Some or all of tha information that you are asked to provide on this application Is classlfied by State law as eithsr private or <br /> confidential. Prlvate data is information which generally cannot be given to the pub�ic but can be given to the subject of the data. <br /> Confidential data is fnformation which generally cannot be gfven t�either the public or the subjsct of the daia, Our purpose and <br /> Intended use of this information Is to annuslly updat�our records and records of other govemmental agencies required by law. If <br /> ou refuse to su I the info ation,the a IlcaUon ma not be issued. <br /> ApplicanYs Signature: . Date: s����T4 <br /> Owner's Signature: Date: <br /> Last Llpdated:03/06/2073 <br />