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. • . City of Orono Building Permit Appiication for Maintenance / Replacement 1 Renovation (No structura! expansion. Only windows, doors, sidin , re-roof, etc.) �OA TO Mailing Address: PeRnit number: �� -�. .y PO Box 66 Crystal Say,MN 55323-0086 Date received: 5fresf Address: Received by: ��s�, G�'' 2750 Kelley Parkway Plan review fe � Orono,MN 55356 t'�k�SN��''�`� /�Q� �1�l ,...�- Total Fee: o«/ Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us (J 'fhis application form must be completed in full and all required information must be submitted. Incomplete apglications wilf be retumed. (Please print) GENERAL INFORMATION: 2� r�� Job Slte Address: J Wfll this be a Parade of Homes, Remodelers Showcase Home or other Dlsplay Home? Yes No !f yes,a special event permit is required wifh Police Depertmenf and Cify Council approva!60 days prior to the event. Shuttle bus rvice will 6e requrred unless spplrcanf demonstrates suffrcient on-site parking!s available. Non-peimitted events will not be aflowed. CON7RACTOR I APP .J,.ICANT INFO TION: I Name: �C.G�I(�iY OS. t..-�1�W�. �.' State License# a 3 =��C� Expiration Date: ' �J /(� Lead Certification Number: J�/-�j��Q. —( Expiration Da#e; �3 ,� � (for work on homes thaf were consfrucfed prlo�to 1978 Phone: (cell} (oifice) .�,��'7 -1�, -�r,-� Mailing Add�ess: (`j U y City: ZlP: '"�'3 Contact Person: �.v^c� h D t�t g►�vi�t�.� _ Applicant is: ntrac / Homeowner �c�r�i.o�e� Emaii and/or Fax: C��/y��,�, �.�C��,,�y��j�+b5�- C.(�lN�. PROPERTY Q1l�lNER INFORMA 10 : Name: O� Z Q..U�So Phone(day): �j� Address: (? b City: ZIP: Email and/or Fax� PROJECT INFORMATION: Overall ro'ectdescri tion: CtC�. ,� 1/1�1L'if�QVt}'S � �.V1 GQ.O D f Type of Project: My earth movement may also requ Door(s) ❑ Remodel ❑Fire Damage MCWD review 8�permlts: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWO) i8202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,othar(specliy) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 �9Jindow(s) www.minnehahacreek.ora Estimated Construction Valuatlon of Project(excluding land} $ APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Bui[ding Department; • Certifies that the information supplied is true and correct to the best of his/tier knowledge. The applicant recognizes that they are solely responsibie 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 infa►mation that you are asked to provide on this applicatian 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 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 annually update our reco►rts and records of other govemmental agencies required by law. If ou refuse to su 1 the' format' n the a 'catioR ma not be issued. Applicant's Signature: � Date: �' �a � ¢ Owner's Signature: Date: La5t Updated:03/06/2013