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City of Orono Building Permit Application for Maintenance l Renovation (windows, doors, siding, re-roof, etc.) Meiling Address: aPO Box 66 Permit number. —4V (� � .� Q 0 Crystal Bay, MN 55323-0066 Date received: 'JYdr Sheet Address: Received by: 2750 Kelley Parkway Plan review fee: o Orono, MN 55356 AUS' Main: 952-24914600 Fax 952-249-4616 Total Fee: !f wv�v v.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. GENERAL INFORMATION: Incomplete applications will be returned. (Please print) Job Site Address: //T0 A,. Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? LJ Yes If yes,a$pedal event permitis requin:d with Porrce Department and CityCouncf/approval 60 days prior to the event. Shuttle bus service w7lbe required unless applicant demonstrates su/tfcient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: e-V- State License# Expiration Date: _� _fit_• �� Lead Certification Number. '� ---^ — Expiration Date: (for work on homes that were onstructed prior to 1978 Phone: (ice) - C/ (cell) Mailing Address: `t City: r ZIP: Contact Person: Applicant is: on ra / Homeowner (ciraie One) Email and/or Fax PROPERTY OWNER INFORMATION; C Phone(day): � 1�4� �`i✓!/a'1�� Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑�oor } j]Remodel Fire Damage MCWD review 8�penrtits: Minnehaha Creek Watershed District(MCWD) f,asphalt ❑Repair ❑Storm Damage J 18202 Minnetonka Blvd ❑Re-roof, cedar ❑Restoration j]Water Damage Deephaven,MN 55391 ❑Re-roof,other(specify) ❑Siding ❑Other.(specify) Phon Faxe952-471-06820 ❑Window(s) mmminnehahacreek org Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ � , APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certlfies 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 r 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 information is to annually update our records and records of other governmental agencies re wired b law: If you refuselEIgMheOWOffRgio—ff-theaDiDlicavon may not be issued. Applicant's Signature: -T`" Date: _ r '7— Last Updated: 08-09-2011