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Mar, 1 ?�. 2013 1'2: 1�8PM � No. 0191 P. 1 .. ' � ' ( . City of Orono Building Permit pplication for Maintenance / Renovatio ; (win ows, ddors, siding, re-roof, etc.) �� �O�� I M iliPO Box 6B� Permit number. a 0! 3 -b0/�p i Crystal Bay, MN 55323-0066 Date reoeived: .3- I- 1 � � , ... .... ...... .. a� a S et A�ldress: Re�eNed by' • . � � • o�`� 2750 Kelley Paricway Plan�review•fee: �g��,� rono,MN 55356 • . . ..... ..;,.. -=--' Totsl Fee`.�.. Main: 952-249-4600 F : 952-249�616 www.ci.orona.mn.us ' • This application form mu completed in full and all required information must be submitted. Incompl appUcatlons will be returned. (Please print) GENERAL INFORMATION:, /� Job Site Address: � � O N 4 S � u !�e- 0� (Z � �, WIII thls a Parade of Homes�Remodeler$Showcase Home or ctt�er Display Home7 Yes No Kye�e al�eHent permit is required with Police DepaRrYient and Clry Counci�app�ave160 deys prior to the event. Shu�tle bus serv�ae wu1 be . required unless appUcant demonstr�tes suAScier�t on-s(te pa�iaing is available. Non-perm'rfted eve�fs will not be allowed. • � I �ONtIZA '�O�/APF�LJ�ANT INF RMA710N: „ � Name: J�c_ �.� ' a � �� d- �U u e,►L. State LiCense# � � � 3 Expiration Date: � -- 3 =�--�� Lead Certification Number: �) �.� g � E'j S'� Expiration Date: ;�,3 -��-' (1�or woilc on hontes the!waa con�hucte�prior to f 978 Phone: � 5 � '�� -� lo (office) �(-� � �;�}rl '� �i � •� (cell) Mailing Address: o �' , � �� '' (�c� Ciry: K�' ZIP: � " �3 � Contact Person; � �4_� h �,,s ,� Applicant is: Contractor' Homeowner �croa o�.�. Email and/or Fax: a •�� , � p, PROPER OV�MER INFORMATION: Name: I �c.` �- D �k, 1n1 � Phone(da ): - - � � Address: � o � N e� s � City: �tZvrJ G ZIP: 553 Email an r Fa�c � y PROJEC INFORMATION: rype of p ec� My sarth movemeM may require MCWD revfew 8 permits: oor(s) I ❑Remodel ❑Fire Damage Minnehaha Creek Watershed District(MCWD) ❑R�roof, ph�lt ❑Repair ❑Storm Damage 18202 Mi�netonka Blvd ❑Re-roof, edar� ❑Restoration ❑Water Damage �ephaven, MN 55391 Phone: 952�71-0580 []Re-�oof, r(spsdy) ❑Siding ❑Other. (specify) Fax: 952-d71-0682 �W�ow�g� www.minnehahacreek.oro Overall P 'eet Descri tion: i�� (' n� � �.��2 S' •�2.� o `, 1L, Estlma Constructlon Valuatlon of ProJect(excludin Iand i �o ��'' APPLICA T ACKNOWLEDGEMENT:i . • Ag s to provide all informadon requiged or requested by the Building Department; • Ce i�es t�at the informadon supplied�s true and correct to the best of his/her knowledge. The applicant recognit�s that they are solely responsible for submitting comple�e application being aware that upon failure to do so,the staff has no attemative b reject it until it is complete, • So e or 11 of the information that you are asked to provide on this application is classified by Sta�e law as either private or co denti�l, Private data is information which generally cannot be given to the public but can be given to the subject of the da . Confidential data is information which generelly cannot be given to either the public or She subject of the data. pur pu ose and intended use of this infortnation is to annually update our records and records of other govemmental agencies re ired b law. If ou refuse to su I the infortnation the a lication ma not be issued. Applicant's ignature: �-1� c� �-n Date: J^f/ -� � Last Updatetl: 06-09-2011