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r • City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) MailingAddress: permitnumber�� Q �0�� Crystal Bay,MN 55323-0066 Date received: � ''� Street Address: Received by: S G�' 2750 Kelley Parkway Pian review fee: `� Orono,MN 55356 t'kESHOQ'� � O�J TQtal Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full end all required information must be submitted. incomplete applications will be retumed. (P/ease print) GENERAL INFORMATION: Job Site Address: � yd /�b R T f� 51�'�� L�k� t►�/1��Z�97�/9 S� 3 9/ Will this be a Parade of Homes,Remodelers Showcase Home or other Dispiay Home? Yes No K yea,a special event permit is required with Police Department and City Counci!approva!60 days prior to the event Shuttle bus se►vice will be requimd unless applicant demonstrates sufhcient on-site parking is available. Non Permitted events will not be allowed. CONTRACTOR I APPLICANT{NFORMATION: Name: D t�U N�1�"`„ d- �� State License# Expiration Date: Lead Certification Number: Expirafion Date: (for work on homes that were constructed prior to 1978 Phone: (cell) (office) Mailing Address: Ciry: ZIP: Contact Person: Applicant is: Contractor / Homeowner �ci�a,e� Email and/or Fax: PROPERTY OWNER INFORMATION; ^� Name: �.]� '� S '�,1� l pY'S P � Phone(day): (�, _ S��1n�-�1.� M l`�PL� Address: �Q 9 3 �/�1�E gr�1o/PC �(`E /�'�{' City: �OL/�tl/� ZIP: �S 3S� Email and/or Fax: � PROJECT INFORMATION: Overall ro"ect description: Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage N�CWD review&permits: �Re-roof,asphalt ❑Repair ❑Storm Damage Minnehafia Creek Watershed Districl(MCWD) 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 ❑Re-roof,otFier(specHy) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.org Estimated Construction Valuation of Project(excluding land) � i I �D, r� � 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 altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is dassified by State law as either private or confldential. Private data is information which generally cannot be given to the pubiic 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 subjed of the data. Our purpose and intended use of this information is to annually update our records and records of other govemmental agencies required by law. If ou refuse to su 1 the information,the a ication ma not be issued. ApplicanYs Signature: Date: Owner's Signature: , Date: �6 Zel� Last Updated:03/06/2013