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. . City of Orono Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) MailingAddress: Permit number: 4`� —D"O 7 g g-��O PO Box 66 — Crystal Bay, MN 55323-0066 Date received: �/—'� � Street Address: Received by: ��,, �' 2750 Kelley Parkway Plan reviewfee: L Orono,MN 55356 /'/,- �) tq'FESHp4`� Total Fee: (�y'�� (/ — Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 7 � 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: c,.� 5� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus s rvice will be required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be al/owed. CONTRACTOR/APPLICAN�T I/N;FORMATION: / Name; �� I�,�st'��S G� �ur^�i�e�i'"� State License# C K��ps Expiration Date: 3/31�1�( Lead Certification Number: NqT-a5o3y-01 Expiration Date: �aa f a a (for work on homes thaf were constructed prior to 1978 Phone: (cell) (office) q5a- 915-7dd6 Mailing Address: y ap �(�;,� (31,, City:S}. I.,a,��s p��k ZIP: �Sy((, Contact Person: �,,� Applicant is: Contractor / Homeowner (Circle One) Email and/or Fax: ��,� (�k �, ;,,,�,�,r„r PROPERTY OWNER INFORMATION: Name: �cKce aw�k� Phone(day): 612- �aN- 9oNa Address: 38o Lo�,F' Sf C�tY� OfsnO Z�P� �53�G Email and/or Fax: PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require ❑Door(s) ❑ Remodel ❑Fire Damage MCWD review 8�permits: �Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ dN.9o0''= APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • 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 submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • 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 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 records and records of other governmental agencies required by law. If ou refuse to su I the information,the a lication ma not be issued. Applicant's Signature: �,��W Ai�z�°"�� Date: ��a�� Owner's Signature: Date: Last Updated:January 2o16