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City of Orono �uil��g Permit Appiication for Maintenance / Replacement / Renovation (No structural expansion. Oniy windows, doors, siding, re-roof, etc.) �O� Mailing Address: Permit number:��7'— U� oZ � O PO Box 66 Crystal Bay, MN 55323-0066 Date received: lU-Z (� �� Street Address: Received by: y �� 2750 Kelley Parkway Plan review fee: `� L Orono, MN 55356 `�KESH�� Total Fee: � �� 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 appfications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: .-`7 � j't,s� �/U� /� �� ''I?/J J , � Will this be a Parade of H mes, Remode ers Showcase Home or other Display Ho e. ❑ Yes ❑ No If yes, a specral event permit is required with Police Department and City Council approva!60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is avaifable. Non-permrtted events wil!not be allowed. CONTRACTOR 1 APPLICANT INFORMATION: Name: �U� � � State License# � � (� 7 O Z; Expiration Date: �1 .�� S� Lead Certification Num er: �� Expiration Date: (for work on homes that were constru ted prior to 1978 Phone: (cell} �L '7�'� c�� (office) S -- J`�f-'Jc�uv Maifing Address: �L,�.�3 �u��j �� -�//U City: .��r�J ,Q,/�'�IP: .j'�3� (,, Contact Person: ��'�,�3� Applicant is: �racfb�i / Homeowner (Circle One) r Email and/or Fax: �-�''-- , � ,� �v.;� �J • � o L'� -'� ��-�' �_ _ C. s� ��—S`��77 G, PROPERTY OWNER INFORMATION: Name: �,�, f��Lc�r ZZ,E,'z--- , Phone (day): �� Address: City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall pro�ect description: �'ype of Project: Any ea►th movement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: �Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq cstimated Construction Vafuation of Project(excluding iand) $ �'� APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the informafion 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 informafion that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generatly cannot be given to the public but can be given to the subject of the data. Confidential data is information which generaliy cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to a nually update our records and records of other governmental agencies required by law. If ou refuse to su I the inform fio ; e a lication ma not be issued. App(icanYs Signature: Date: D �' 4wner's Signature: � Date: �ast Uociated: 03/06/2013