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City of Orono . Building•.Permit Application for Maintenance /'Renovation .• . (windows, doors, siding, re-roof, etc.) • _ • Mailing Address: • Permit number : p20//- l)6 g 1.O4 Crystal Bay. MN 55323-0066 Date received: J .�(e/w 1/4;-':‘ , ►i.�, • > StnaetAddmss: R5CB�led by: 14. ` ^� <� 2750 Ke118y Parkway Plan review flee: �' ' Orono,Po MN 55356 • • Total Fee: • Main: 952-249-4800• Fax: 952-249-4618 . www.Ci.prono.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: ! • Job Site Address: . •4a() Orchrd Par Kd CAOr.o, r'nrN55 3 5 , Will this be a•Parade•oif Homes,Remodelers Showcase Home or other Display Home?. •. ❑Yee : fa No if yes,a special.event permit•is rooked with Police Department and City Council approval 50 days prior to the event Shuttle bus servx a will be required unlees'applicent demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR 1 APPLICANT INFORMATI(e�N: • Name: .zix.vdt.oaCt 9.00- -l ' t-3vL State License# •. a•O•S'71.04‘..4g Expiration Date: S 1 at o i a Lead Certification Number.,• . • Expiration Date: (for work on homes that weie Constructed prior to 1978 Phone: • 3 -:.- Q03= t a91 (office) : 3ao•'RV• S$pci . (cell) Mailing Address:1 .3900. ( oo'be.el i.2:T Iv a • .. •• . City: (0‘4.4 .. ZIP:• cjfo 301 Contact Person': --t .A r-e• "-c.-.1„or tke, Applicant is: ontractor / Homeowner (circle one) Email and/or Fax: t ii., ( 2o.)31cic root r•cs. Covr.., -5ack•a 3o• 4tot4 PROPERTY OWNER INFORMATION: Name: P)3\ o...4 Ly r c gem rso..-- Phone(day): Co,a. 134, % a3 • Address: tvao or ct.o.e d 945.4-14‘. ' . City: Or o r.p ZIP: SS 35(o Email and/or Fax PROJECT INFORMATION: • Type of Project . Any earth movement may require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) XRe-roof,asphalt 0 Repair 0 Storm Damage 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration 0 Water Damage DeephPhone:v95 MN 55391 Phone: 952-471.0590 ❑Re-roof,other(specify) 0 Siding 0 Other.(specify) Fax: 952-471-0682 ❑Window(5) www.minnehahacreek.oro Overall Project Description: e e..e ,4f) q,ne ((g,- •61N..• -t; - Estimated Construction Valuation of Prooct(excluding land) $ It.000.00 . 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 df the data. Our purpose and intended use of this information is to annually update our records and records of other govemMental agencies required_y law. If you refuse tb supply the information the application may not be issued. Applicant's Signature: � �G�--i C ' `+.1��. I c�Date: i 5l 11 Last Updated: 08-09-2011 IO/TO 39t/c1 DNI 9NIJOOd I>IDO1EVZ TO 9E:91 t10Z/9Z/80