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City of Orono Building Permit Appl cation for Maintenance/Replacement/Remodel - Residential ONLY (i.e. windo s, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) �o A I Mailing Address: t( -C / 0 PO Box 66 Permit number: • Crystal Bay, MN 55323-0066 Date received: /Z�II(Q Street Address: Received by: �_Q S� 2750 Kelley Parkway Plan review fee: L Orono, MN 55356 �/ !A'�fSHO�� I Total Fee: / _/ _9, qa Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us w ll/ This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GEJob Site L INFORMATION: TION:/os- ��LO �� y, Ad . t . Job Site Address: Los- 11 Will this be a Parade of Hones, Remodelers Showca ome or other Display Home? 0 Yes Ii No If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus seiv".- will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICAN INFORMATION: - Name: ) t CR � UAj , , State License# Qrto • Expiration Date: Q _ a. Lead Certification Number: 1... I — r - Expiration Date: 2.tiff (for work on homes that we - constructs• prior to 1978 Phone: (cell) 4A.. i-2_„ , - s (office) t ' --1 , •— Mailing Address: `s all rat a' MEIIIIIIIIIMMIEMNIVOIL.7_&,.:0i1i 44.1 Contact Person: AEA , 1111M1131 i A AA 1, Applicant is: - .n1 actor Ho j owner (circle one) E Email and/or Fax: ,rylr • i , Mt A J MI �_, I L� PROPERTY OWNER INFOR ATION: Name: 1 i DI . C'1CULYU,1,0 Phone(day): 4" -Z- ' , 4 • Address: /OS- r 0 f i C p ,i City: Otke-yuo ZIP: ,c-c--5S-1, ^ � Email and/or Fax: MAI /1 r 1 5 0 4 we-C� J 0 • Larvt J n PROJECT INFORMATION: Overall project description: 2e- -12-$r/1. Type of Project: Any �movement may also require ❑Door(s) 0 R-model 0 Fire Damage MCWD review&permits: We-roof,asphalt 0 R-pair torm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑Re-roof,cedar 0 R storation 0 Water Damage Minnetonka, MN 55345 12 Re-roof,other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 0 Window(s) www.minnehahacreek.orq Estimated Construction Valuailon of Project(excluding land) $ (-1-31 (n(hfl APPLICANT ACKNOWLED EMENT: • 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 I1 e inforn'ation,the application may not be issued. __?21.2afifp Applicant's Signatu • AI.:1 A A A,,I/_ r ‘All4 . Date: Owner's Signature: / Date: Last Updated:January 2016 I