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Mar. 28. 2018 9: 53AM No. 4478 P. 1/2 City of Orono Building Permit Application for Maintenance/ Replacement 1 Remodel-I i side i ial`ON:a (i.e.windows, doors, siding, re-roof,etc.—NO STRUCTURAL EXPANSION) Mailing Address: ,,:.m:. _: ;,. .:_ 4,4 PO Box 66Permit�tiiirlii" °" :_ Crystal Bay,MN 55323-0066 Da eceIvetl_ _--.:::,..::_..r.-::/ * . esery Street Address. edllby E. v. ._. .. • 2750 Kelley Parkway 'PI.2ICIJ vi9.wfee : �: - G Orono,MN 55356 __ lt,:litSti-100 - - - TotafFee,v _ - Fax: 952-249-4618 www.ci.orono.mn.us -_ _ -_ ?.. Main= 952-249-4600 - - _ ...,,.,f r:m,:�,;.; �: p' This application form must be completed In full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: y 5- � ^ 1 tQ,r Job Site Address: V IL)' �'7 � Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? 0 Yes 1;11 If yes.a special event permit is requirgtl with Police Department and City Council approval 60 days prior to the event. Shuffle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wit not ba allowed. CONTRACTOR/APPLICA T INFORMATION: C r� Name: �Q Y�.- • i( € Scr Lit — LLIc 1�7 nn S' State License# mT rExpiration Date: 3 f�(-) Lead Certification Number: -.EZ D r Expiration Date: 5 I I.-7 1 (for work on homes that were constructed prior to 1978 Phone: (cell) • (office) Mailing Address: ( 5"j .p �c (5-1 „Jr OJj val.- City: 1�.t`y1S ZIP: ' ,5 31,4 3 Contact Person: \CUt Jv r, Applicant is: ontractor I Homeowner (circle one) Email and/or Fax: ft,,-::;-.7-,,,_, c_,_ J „thy. 7 . . ( 0,„...__. _ PROPERTY OWN �Y��TIt�� Name: \ :ne(daY); e9- a�_-� ` ress: ) 37 0 /v a l id ` l City: Q e -ZIP: J c 3 =1 Y , Email and/or Fax: V PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require 12Door(s) ElRemodel 17 Fire Damage MCWD review Si permits: CIRe roof,asphalt 0 Repair L)Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 ❑Re-roof,other(specify) ❑ lding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682wi indo_w(s) 2wwinnehahacreek.orq Estimated Construction aluatlon of Project(excluding land) $ )a 5 `j' --:-- 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 an ally update our records and records of other governmental agencies required by law. If you refuse to supply the i fi ation,th I ppfcation may not be Issued. lA Applicant's Signature: /� , I /' Date: 14E> Owner's Signature: Date; Last Updated:January 2016