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City of Orono Building Permit Application for Maintenance I Renovation (windows, doors, siding, rer000f, etc.) hh__ Mail PO Box f3$ Permit number: --2 eV - �- o1. Y6 Crystal Bay,MN 55323-0066 Date received: x/34 T. ts Sheet Address: Received by: 'ii ...11,- 2750 Kelley Parkway Plan review fee: ' i�, Orono, MN 55356 Total fee: l(71-V,-,0140 Main: 952-249-4600 Fax: 952-249.4616 www.ci.oroup.mn.us This application form must be completed in full and ail required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: 3 (CC 0 •( v` c Lcu\-t Job Site Address: o Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? NI Yes M No it yes,a special event permit is required with Police Department and City CounCA approval 60 days puerto the event- Shuffle bus service will be required unless applicant demonstrates sufficient onsite parking is available. Non-permitted events will not be allowed. CONTRACTOR l APPLICANT INFORMATION: Name: r lel.. ..‘ .- flasbuser, State License# C.1349$3 Expiration Date: 3 i Si Lead Certification Number: ik„)' ` -- a c $3 -t Expiration Date: 4/IC (for work on homes that were constructed prior to 1978 Phone: (& l— a • -4.0 s'$- ; , (office) (cell Mailing Address: • . . C•. 1 . " _ •. W eCity: ,. ; t ZIP: 551 3 Contact Person: Applicant Is: .antra. / Homeowner (ctrrieone) Email and/or Fax: . PROPERTY OWNER INFORMATION Name: ir 4. l.%0 Phone(day): t tart -- 'lb— I • Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Protect: Any earth movement may require ❑Door(s) ❑Remodel 0 Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Re-roof,asphalt 0 Repair 0 Storm Damage 18202 Minnetonka Blvd Deephaven,MN 55381 ❑ Re-roof,cedar 0 Restoration ❑Water Damage Phone: 952-471-0590 ❑Re-roof,other(specify) 0 Siding ❑Other_(specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ort Overall Project Descri• +on: ' ',• • ii 11J+ a C� LAJ) A -'5ire- r" Estimated Construction Valuatlo of Project(excluding land) $ r '>9./ 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 oan 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 •u refuse to su,•I the informatiokthe application manot be issued. •QcI ) Applicant's Signature: / I 1 r✓�-- - / Date: 3 t