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v City of Orono Building Permit Application for Maintenance / Replacement / Remodel - Residential ONLY (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) i �!VOMailing Address: Permit number: PO Box 66 �jllim RCrystal Bay, MN 55323-0066 ECEIV a received: Streef Address: Received by: 12 2750 Kelley Parkway �CTI 2U Flan review fee: Orono, MN 55356 fkestio�`� CITY OF OROIVTO tal Fee: 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: 19 3 0 ffei -tf c., . Will this be a Parade of Homes, Remodelers Showdase Home or other Display Home? ❑ Yes [ -No 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 Licei15300 25th Ave N Ste.100 Expiration Date: Lead Certi Plymouth MN 55447 E15-17$2.--( Expiration Date: -I-7-w Phone wor 763-745-1400 $ (office) Mailing Aa BC645090 expires 3/31/19 City: ZIP: Contact Person: _j li_s) 'L Applicant i Contract / Homeowner (Circle One) Email and/or Fax:id i e.fG�eActe..0 or.ES.CCAn l PROPERTY OWNER INFORMATION: Name: Cr 6r umay\ Phone (day): J(p(i- SW-810 -( Address: City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require ElDoor(s) ElRemodel iiiFire Damage MCWD review&permits: 1:1 Re-roof,asphalt ❑ Repair III Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka,MN 55345 CI Re-roof,other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 kWindow(s) //WM. '`�( ,to I4 Y4 www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ (07) .SZl' 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 This infor •ation is to annually update our records and records of other governmental agencies required by law. If you refuse to sup ly tr- information,th a plication may not be issued. -7 Applicant's Signature: ,-,J� / Date: l0— —/ Owner's Signature: Date: Last Updated:January 2016