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_ � - � ' City of Orono ' � �� � �� Building Permit Applicafivn for IV�aintenance / Renovafion A� 3 F d (windows, doors, siding, re-roof, etc.) �xy Mailing Address: Permit number: p� �-� � t g,0,� PO Box 66 / �; ; � �a � Crystal Bay, MN 55323-0066 Date received: �! '� �a ;�i;, �, I Street Address: Received by: .�, �� Gti 2750 Kelley Parkway Plan review fee: �'" t'�.kEs� Orono, MN 55356 f � Total Fee: 9�Q, ��J" �' Main: 952-249-4600 Fax: 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 returned. (Please print) ;; GENERAL INFORMATION: /� �; Job Site Address: ��DU � /LCS�Z� /� f� v �'. v Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No !' If yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the evenf. Shuttle bus service will be � a.i: required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ``"� i`;� ' CONTRACTOR/APPLICANT INFORMATIQN: • �'` Name: A L�S; �'�on,5=T o c � State License# ��,3j�� Expiration Date: ,� 3 i iv �" i Lead Cerfification Number: Expiration Date: �1 (for work on homes thaf were construcfed prior fo 1978 Phone: '7(3.- 7y �'-�a u (office) �" ,� (cell) � Maiiing Address: �i5l� �,i/p��;,�� j-�— City:�L4�CG �i�,R/ ZIP: ��3 �?� � Contact Person: �,_ S6 t-{N Applicant is: Contractor / Homeowner (Circle One) Email and/or Fax: �� �� PROPERTY OWNER IN ORMATION: ; Name: �j �t��..J�L(_.. '` ,� Phone (day): �� j g ` Address: � ; lr�e� . ��ST�.� (`1D City: U`Le��Ja ZIP: � i� Email and/or Fax 'i ';°; � �. PROJECT INFORMATION: � � T e of Pro'ect: r '( YP 1 Any earth movement may require � � � ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: ; "f ❑ Re-roof, asphalt ❑ Re air Minnehah a Cr e e k W a t e r s h e d D i s t r i c t(M C W D) �� p ❑ Storm Damage 18202 Minnetonka Blvd _''; �Re-roof, cedar ❑ Restorafion ❑Water Damage Deephaven, MN 55391 `� ❑ Re-roof, other s eci Phone: 952-471-0590 � , ( p fy) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 rt`,i ❑Window(s) www.minnehahacreek.orq ; ,i Overall Project Description: (E��-�_ �c� � ��,= ': 7 y'' :,; Estimated Construction Valuation of Project(excluding land) $ "7g�p.� :i � �;i APPLICANT ACKNOWLEDGEMENT: £k ,G • Agrees to provide all information required or requested by the Building Department; � i 4 • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they ;� are solely responsible for submitfing a complete appfication being aware that upon failure to do so, the staff has no alternative �' � but to reject it until it is complete; ; r :; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the " ° 1 data. Confidential data is information which generally cannot be given to either the pubfic or the subject of the data. Our � purpose and intended use of this information is to annually update our records and records of other governmental agencies :;� re uired b law. If ou refuse t u I the information,the a lication ma not be issued. "i ApplicanYs Signature: Date: l� � // ;; I ` Last Updated: OS-09-2011