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Uty oT urono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: d _ 0�0,�0 _v PO Box 66 Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: Q � 2750 Kelley Parkway Plan review fee, e o�� Orono, MN 55356 Total Fee: �02� Main: 952-249-4600 Fax: 952-2494616 www.ci.orono.mn,us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please prino) GENERAL INFORMATION: �,�,�� .lob Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 12 Yes ❑ No If yes,a special event penult Is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus services will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted evenis will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: .scl�c.�t�-F�v y State License# 0_,e>z Z C,�, OZ- Expiration Date: 3•3,1 - 1 2- Lead Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 9978 Phone: ` C .T7 S „ `� (office) (off 2,ZjZ _3228(cell)- Mailing Address: 93 g a .'j�!4 U ZIP: :5S4 3Z_ Contact Person: _73'= Applicant is: ontra or Homeowner (circle one) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: )a4 — S b© a!1 Phone(day): ' �z - ?YL. 2 , Address: yy c'(o AJ — f� _ City- �r 0,2 cp ZIP: Email and/or Fax 9s z - —7,y Ll -s g3 PROJECT INFORMATION. Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) XRe-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd ❑ Deephaven,MN 55381 Re-roof, cedar ❑ Restoration ❑Water Damage Phone: 952-471-0590 Re-roof, other(speciry) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 ❑Window(s) www.minn hahacreek.or Overall Pro ect Description: Erg 1,J Estimated Construction Valuation of Project(excluding land) $ Z15I 1 3 L4 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 or ion which generally cannot be given to the public but can be given to the subject of the data. Confidential data i In m on which generally cannot be given to either the public or the subject of the data. Our purpose and intended a of t i , formation is to annually update our records and records of other governmental agencies required b law. If you efuse t I t ormation,the application may not be issued. Applicant's Signature: Date: Last uoaatea: 0e-09-2011-1 ze/ie SDtld NOIiOndlSNOO DNS L6b856LE9L H :ET ZTeZ15Z/6e