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OCT/06/2016/THU 10:33 AM Elder Jones Building FAX No. 952 854 4909 P. 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: 0140/4)--4'0‘-7 {VQ PO Box 68 Crystal Bay, MN 55323-0066 Date received: —/p Street Address: Received by: 2750 Kelley Parkway Plan review fee: �keskto�`` 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: �{ q O 1 c!„/ 40 /) 9, / ed t a- Road o V„/ Job Site Address: L, Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 0 Yes D No If yes,a special event permit Is required with Police Department end City Council approval$0 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: Pella Northland 6 n y 7 J o d1 State License# 15300 25th Ave N. Ste 100 Expiration Date: Lead Certification Numbe Plymouth,MN 55447 Expiration Date: (for work on homes the Phone: (cell) Lic#BC645090 Ph. 763/745-I400 (office) Mailing Address: ZIP: Contact Person: Applicant : Contractor omeowner (Circle One) Email and/or Fax: i n of it 5 41) g f d 4 I' L o /)_Q 3_ f 0 111PROPERTY OWNE INFORMATIOftr rl Name: 4 l' t•y WI f� e Phone(day): 6 /2 ( 8oS • Ron2 7Q�G Address: �( �Q b// L 0 ? Z aft GIa Rd City: Y ZIP: 5 5 3 q/ Email and/or Fax: PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require 0 Door(s) ❑Remodel IDFire Damage MCWD review&permits; ❑Re-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑ Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka, MN 55345 ❑Re-roof,other(specify) ❑Siding CD 0 Other. (specify) Phone: 952-471-0590 Fax: 952-471-0682 Window(s) www.m innehahacreek.oro Estimated Construction Valuation of Project(excluding land) $ 3, 7 5" .5" 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 sup ly the information,the application may not be issued. Applicant's Signature ,. Date: /9 / L Owner's Signature: Date: Last Updated:January 2016