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OCT/09/2017/MON 01 : 44 PM Elder Jones Building FAX No, 952 854 4909 P. 002/002 City of Orono Building Permit Application for Maintenance / Replacement I Remodel — Residential ONLY (i.e.windows, doors, siding, re-roof, etc. --NO STRUCTURAL EXPANSION) c� Mailing Address: Permit /7- 01�o PO Box 66 /� Crystal Bay,MN 55323-0066 Date received: 7Q?/ 2 7 Street Address: Received by: ti 2750 Kelley Parkway Plan review fee: `�r G Orono,MN 55356 �i�j 41c4HOR� g 6q✓- Total Fee: 5-7 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. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: 198o fit ui� Will this be a Parade of Homes,Remodelers Sho ase Home or other Display Home? Ei Yes Vo If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: Pella Northland State Licei 15300 251h Ave N Ste.100 Expiration Date: Lead Certi Plymouth MN 55447 r(5(7 8 2~i Expiration Date: 9—7—z(7 Phone wet 763-745-1400 s (office) Mailing Ad BC645090 expires 3/31/19 City: ZIP: Contact Person: ,� �� Applicant iC Contract / Homeowner (Circle One) Email and/or Fax:it)1 t'e,. '( c !}CIYles,COW) PROPERTY OWNER INFORMATION: LJ Name: [rreg 6ruvnaVt Phone(day): S' _810-( Address: City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall project description: Type of Project Any earth movement may also require ❑Door(s) ❑ Remodel ❑Fire Damage MCWD review&permits: 0 Re-roof,asphalt 0 Repair El Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑Re-roof,cedar 0 Restoration ❑Water Damage Minnetonka,MN 55345 Phone: 952-471-0590 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Fax: 952-471-0682 kWindow(s) /ruin. eytp 1rar.4 www.minnehahaoreek,orq Estimated Construction Valuation of Project(excluding land) $ (07�57)--0 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. 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 is infopation is to annually update our records and records of other governmental agencies required by law, If you refuse to sup ely t•e information,t as plication may not be issued. G� -7 Applicant's Signature: 1� " — Date: /a- ! r/ Owner's Signature: Date: Last Updated:January 2016