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City of Orono Building Permit Application for Maintenance / Replacement / Remodel —111006#040- lLY (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) V.,01V Mailing Address:PO Box 66 IPermit number: Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: ti LAt. 2750 Kelley Parkway Plan review fee: Orono, MN 55356 /� IKESHO�� / �'. I Total Fee: V666 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) INFORMATION: Job Sito Address: /5 `o ,. 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 required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORM ON: _ Name: s/ _ State License# 1! 11110 •- Expiration Date: /vl a D 2 Lead Certification Number: A)19---/--- Oj i(..)f -2- Expiration Date: _ • (for work on homes that were constructed prior to 1978 Phone: (cell) 6./a- -2/- Z 3 S j (office) 9 '- /-73 . zf2S-7 Mailing Address: 34,2z7 City: /-0/1 4/we ZIP: 'ic33Z Contact Person: Applicant is: Contractor/ I Homeowner (Circle One) Email and/or Fax: ,6.s o, pit 00 I mo_ PROPERTY OWNER INFORMATION: Name: C,t"1 611.1-e-5 /lie.& I/ Phone (day): Address: / lO CoG 9t i7/y9- 31. City: O,1..07A..0 ZIP: 3--)--3 / Email and/or Fax: 4,iQ.4-ce PROJECT INFORMATION: Overall project description: ��ti 7*11ivJ>rd0C)3 i�y�i SS 1 .- /2. Type of Project: -Any earth movement m y also require ❑ Door(s) 111 Remodel 1:1 Fire Damage MCWD review&permits: ID Re-roof,asphalt ❑ Repair 111 Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 ❑Re-roof,other(specify) ❑ Siding ElOther: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ,Window(s) www.minnehahacreek.org Estimated Construction Valuation of Project(excluding land) $ b�( / i 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 supply the information,the application may not be issued. Applicant's Signature: � ` � � Date: - 2. _ I" Owner's Signature: L h t'�-. ) Date: yl 2J• 2"- Last Updated:January 2016