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� < < � City of Orono Building Permit Application for Maintenance / Replacement / Remodel (i.e. wind�ws, doors, �iciing, i.e-��ao�, e�c. •�M NQ ST�rUCTURAL EXPA�lSION) ,�O A r Mailinq Address: ��(C'�. c <y PO Box 66 ermit number: � � CX� _�� � Crystal Bay,MN 55323-0066 �� Date received: C� -� �I - 1�=� Sfreat Address: � Z �� '` ' �2«5�. � ��y ��. tiF � 2750 Kelley Park � �-�iL �� n review fee: �l.v l�kESH�a�` Orono,MN 553 ti �� ' - �� � Total Fee: �/��Q . �(..}- Main: 952-249-4600 Fax: 952-249-4616 w�wv.ci.orono.mn.us � v This application torm must be compleied In full and all required information must be submitted. �y„�9 5��,� �� Incomplete applications wiil be returned. (Please print) GENERAL INFORMATION: /jG N S � � W � �N S 3 9/ Job Site Address: lJ � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No If yes,a special event permJt Is required wHh Police Departmenl end Clty Council approval 60 days prlor to the event. Shutfle bus service wil!be required unless epplicent demonstrafes suHicfent on-sile parking Fs avallabla. lJon�em►itted events wAl nof 6e a!laved. CONTRACTOR/APPLICANT INFORMATION: Name: �'J I LSS State License# ��, 5924�3 Expiration Date: 3 31 / Lead Certification Number: j�u/LT /N / `� Expiration Date: (for work on homes ihat were consiruct d prior to 1978 t� Phone: (ceil) . � 8 y� (oifice) � qSZ' 7�D s ' ,�j�g 2- Mailing Address: City: � p� p /j/ ZIP: 3 Contact Person: ANO Applicant is: racto I Homeowner �ck�io o�� Emafl and/or Fax: �,ND�rm t[�Ni2.14��'L e�l pRN!E 5�G�M PROPERTY OWNER INFORMATION: Name: �m�g-S G'pN�t/�t�'! Phone(day): 6c1[G . �ZS• �{S 0 8 �� ' Address: 3�l S /►/ S,Stdll� p/y CitY: w�KZ,f��'76 ZIP: 3 Email and/or Fax: _ 7--�•aNA/�� //� QYh�I j •� PROJECT INFORMATION: Overatl ro'ect descri tion: Cf�L ��— Type of ProJect: Any earth movement may also reyuire ❑Door(s) �Remodel ❑Fire Damage MCWD review&permits: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed Districl(MCWD) 18202 Minnetonka Bivd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,oth�r(specify) ❑Siding ❑Oiher:(speciy) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) rnwv.minnehahacreek.orq Estimated Construction Valuation of ProJect(excluding land) a D D� �' APPLICANT ACKNOWLEDGEMENT: • Agrees to provide ail informalion required or requested by the Building Department; • Certi�es lhat the information supplied is true and correct io lhe besl of hisli�er knowledqe. The applicant recognizes that they are solely responsible tor submitting a complete application being aware that upon failure lo do so,the staff has no alternative but to reject it until fi is complete; • Some or aN of the tnformation that you are asked to provide on this appqcafion is ctassified by State law as efther private or confidenpal. Private dala is information which 9enerally cannol be given to the public but can be given lo the sub}ect of lhe data. Confidenlial data fs in(ormaUon whlch generally cannot be given to either the pubNc or the subject of lhe data. Our purpose and fntended use of Ihis in(ormation is to annually update our reco�ds and records of other govemmeMal agencies required by law. If ou refuse to s i t �formation ihe a lication ma not be issued. Appticant's Signature: Date: Owner's Signatw�e: �� K. �� Date: 5��?�l S Last Updated:January 2015