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OCT/17/2017/TUE 03:21 PM Elder Jones Building FAX No, 952 854 4909 P, 002/002 City of Orono Building Permit Application for Maintenance / Replacement/ Remodel — Residential ONLY (i.e.windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) OA, Mailing Address: Permit number: CZU VO PO Box 66 Crystal Bay,MN 55323-0066 ^ Date received: Street Address: Received by: yF 2750 Kelle Parkwa J-I� 4t, C� Y YPlan review fee: �kFSH0�� Orono,MN 55356 10—t -6_t-7 Main: 952249-4600 Fax: 952249-4616 I.Orono.mn.us I Total Fee: 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: Will this be a Parade of Homes, Remodelers Showcase 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 req(Jlrey AnV lil•Anf HP—f—f—ff",..,.„r,,,`17 Is available, Non-permitted events will not be allowed. Pella Northland CONTRACTOR/All 15300 25th Ave N Ste.100 Name: State license# Plymouth MN 55447 _763-7451400 Expiration Bate: Lead Certification Ni X t5)—)I� Expiration Date: (for work on homs BC645090 expires 3/31/19 Phone: (cell) y (office) c�s-{� � �t Mailing Address: Cit : ZIP: Contact Person: Applicant is: Contractor / Homeowner (Circle One) Email and/or Fax: (��4 (D,fNt-lrtYlf-S c-ogf fN PROPERTY OWNER INFORI ATION: 1 Name: y �ErtSSC7'✓� Phone(day): (Q(Z ",53 Z—M Z0 Address: City: ZIP. Email and/or Fax: PROJECT INFORMATION. Overall project description: Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel El Fire Damage MCWD revlew&permits: Minnehaha Creek Watershed District(M CW D) El Re-roof,asphalt El Repair El Storm Damage 15320 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 ❑Re-roof,other(specify)� ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 Windows) www_minnehahacreek.ora 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 info ation is to annually update our records and records of other governmental agencies required by law. If you refuse to su I information the application ma not be issued. Applicant's Signature: Date: /0-17-17 Owner's Signature: pate: Last Updated:January 2016