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City of Orono Building Permit Applic tion for Maintenance / Renovation (windowsl, oors, siding, re-roof, etc.) Mall/ngAdd s: Permit number, Cr Box B Crystal Bi y,MN 58323-0068 Date received: 'Z "�• ,s p+ Street Addres Received by: 2750 Kell Parkway Plan review fee: $� Orono.M 4 55358 Total Fee: Main: 952-2494600 Fact: 952-24 16 www.ci.orono.mn.us This application form must be Compl ted in full and all required information must be submitted. Incomplete appili ations will be retumed. (Please prinD GENERAL INFORMATION: Job Site Address: S - -t, Omvknp AAJ Will this be a Parade of Homes, Remodeiers St owcase Home or other Display Home? LJ Yes No /lYea,a special event pe►mft Is required wfth Police Depar ment and city Cound/approval 60 days prior to the event. Snurde bus Service wt►l be required unless applicant demonatrates sots wt on-alta parking is available. Norrpennlfted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: State License# C 615 q q Q^1 Expiration Date: ( OI Lead Certhication Number. - Expiration Date: 'Z f l 90(g-- (for g-(for work on homes that were constructed prior&1978 Phone: qS'a-qa,p- (office) (cell) Mailing Address: Lt ,, (w City: ark• ZIP:SSS 4 Contact Person; �`� , Applicant is: Contractor I Homeowner (cwtone) Email and/or For. PROPERTY OWNER INFORMATION: Name, Phone(day): Address: li S to -'00A, City: cc- ZIP: S 3 Email and/or Fax PROJECT INFORMATION: - - - --- - Type of-Project. -Any earth movement may require 11Door(s) ❑"Remodel Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) Oft-roof,asphalt ❑Repair E Storm Damage 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration E Water Damage Deephaven,MN 55391 Phone: 952-471-0590 ❑Re-roof,other(specify) ❑Siding E Other(specify) Fax: 952-471-0682 ❑Window(s) www.minnehahscreek ore. Overall Project Description: e&c- oPrC ^ ;- ,Q.o� Estimated Construction Valuation of Project(e luding land) S 1 00. ° — APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all Information required or ested by the Building Department; • Certifies that the Informadon supplied is true a id coned to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complel 3 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 a d to provide on this application is classified by State law as either private or confidential. Private data is information whi generally cannot be given to the public but can be given to the subject of the data. Confidential data is Information which enerally cannot be given to either the public or the subject of the data. Our purpose and Intended use of this information s to annually update our records and records of other governmental agencies re uired by law. If you refuse to smwlythe In don,the appll2pllon may not be Issued. 01/1 Applicant's Signature: nt' Date: q 1 X I96 sia Last Updated: 08-09-2011