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. . .. � , _. y�, ,..'3`-��Fr�!'f_�@G'+'r j� `y,�x. dy�.+c } l� 7 ta# .+pA}I a City of Orono , Bu�ilding Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) � Mailing Address: �Q A rO , Permit number: �G I�J -QJ �(� � ' !y PO Box 66 o- : Crystal Bay, MN 55323-0066 ��G�- Date received: �'Z � �_ � � Street Address: -� t��w Received by: � ' 6 � 2750 Kelley Parkway '� ' 1 Plan review fee� �`�� `�t �' Orono, MN 55356 � �`�� �kESH�� . �< Oi �� �� Total Fee: A � .�,;,', 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. �s' Incomplete applications will be returned. (Please print) � �-; GENERAL INFORMATION: � t� Job Site Address: �:�j2. I�v21 ' ' t= ��:lVe ' �� , 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 approva160 days prior to the event. Shuttle bus rvice will be �� required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. "� � �' ��= CONTRACTOR/APPLICANT INFORMATION: � ' Name: M f I��T �bO��N� . �N c. � State License# ��(�. Expiration Date: Lead Certification Number: /.i ��. Expiration Date: � (for work on homes that were consfructed prior to 1978 � Phone: (cell) office a �� - 33i�- i31£� ( ) 9�Z- y73 - So� �� Mailing Address: 22$� ' �� rL S-T-_ City:LcarvV �E ZIP: 5� � �, Contact Person: So5 �., Applicant is: o rac or Homeowner (Circle One) ,� Email and/or Fax: '�S , �j,�..}- � � �� PROPERTY OWNER INFORMATION: �� Name: wA;'Z!�TA Mq� I N� ZN C- � Phone (day): � Address: 33 NortrH SHd2 �►z City: �4yLA�i R ziP: 553�11 Email and/or Fax: q�V�� -�-q��y,y� _��✓l %� PROJECT INFORMATION: Overall pro�ect description: ��`'�ov� �x�S�f ti"� �>"� ��h T� ��s�.0 �� Type of Project: Any earth movement may also require ��Y �R� ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: � � ' Minnehaha Creek Watershed District(MCWD) �:' ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd h� ° ' ❑ 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 � , Estimated Construction Valuation of Project(excluding land) $ 2 � � 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 E# 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. � t >�� ApplicanYs Signature: ?�" -- Date: � �.h '� Owner's Signatu : Date: �; Last Updated: 03/06/2013 Q�D�-iJ'� — �� c��f 't 1-'lNA� i�"S� . � (� •2�- �,? � /J d� r ��