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City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: Og, jVO Cr Box 66 Crystal Bay, MN 55323-0066 Date received: a Street Address: Received by: 2750 Kelley Parkway Plan review fee: �9xE3H0 Orono,MN 55356 Total 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: qt's 14• Sham ctJ w Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes -0-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: Selo, R004nC4 Q.T- ► 1&TrW& M, State License# low Expiration Date: 3150 Lead Certification Number: • 250314-1 Expiration Date: g /6 _ (for work on homes that were constructed prior to 1978 Phone: Ci%-qV5-`7*1 C (office) (cell) Mailing Address: L{JQQ Ca,! ;0r TWCity§ ZIP: Contact Person: DtAxy-a- LAA; k, Applicant is: ontra / Homeowner (circle One) Email and/or Fax: Ct Sa.�a.Coo4t,n4 arm PROPERTY OWNER INFORM TION: Name: _ �pk_4— Vr Phone(day): _p /� Address: `U S�'lcX� City:Ors n p ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑Door(s) ❑Remodel ❑Water Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Siding ❑ Restoration ❑Other:(specify) Deephaven,MN 55391 Phone: 952-471-0590 e-roof ❑Fire Damage Fax: 952-471-0682 www.minnehahacreek.org Overall Project Description: -TEOL- - G.n x`!'00 +gL+4-a� gpn4A..2 Estimated Construction Valuation of Project(excluding land) $ 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 information is to annually update our records and records of other governmental agencies required by law. If you refuse to pply the information,the application may not be issued. I Applicant's Signature: JLl�.� Date: �°��0/1 Last Updated: 03-01-2011