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City of Orono Building hermit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: ¢,U � PO Box 66 Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: It 114: Gtiti 2750 Kelley Parkway Orono, MN 55356 Plan review fee: fEsso4� 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:II11 Job Site Address: \ CDr on O nerckc.-l 12c� ,. IV_ Will this be a Parade of Ho es, Remodelers Showcase Home or other Display Home? 0 Yes 'IKNo If yes,a special event permit is quired with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless app'cant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICAN INFORMATION: Name: 0.8w.es V 8,-s t. c1uS State License# BI.0107Expiration Date: 3-31 - 'Z 014 Lead Certification Number: 2.037S-- I Expiration Date: $-S.-ZC1/S (for work on homes that we constructed prior to 1978 Phone: 7V3-Li 7 --96 no (office) (cell) Mailing Address: toM51 ,c_ctivvore GA-. &) City: -1ZIP: � 3(0 9 Contact Person: Ike Applicant is(" ontractor / o 5 meowner (circle one) Email and/or Fax: PROPERTY OWNER INFOR TION: Name: Od%A..4,A I (z.j d'e-q Phone(day): 7S-2--V-3 -62_( Address: 1'3S(_roA-0 O r-� Rd . j..-) City: lc" Ictre ZIP: ^,S'' 3 5 Email and/or Fax I PROJECT INFORMATION: 1 Type of Project: 1 Any earth movement may require ❑Door(s) 0 Remodel ❑Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Re-roof,asphalt ❑Reoair ❑Storm Damage 18202 Minnetonka Blvd We-roof,cedar ❑Restoration 0 Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑Re-roof,other(specify) 0 Si4ng 0 Other:(specify) Fax: 952-471-0682 0 Window(s) www.minnehahacreek.org Overall Project Description:i aec 'r Re, Root 73 S,. o-P cd� 5(n�Kzc. Estimated Construction Valuat on of Project(excluding land) $ $ ) 000 APPLICANT ACKNOWLEDGMENT: • 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 sumitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is comp) te; • Some or all of the informatio that you are asked to provide on this application is classified by State law as either private or confidential. Private data is formation which generally cannot be given to the public but can be given to the subject of the data. Confidential data is in ormation which generally cannot be given to either the public or the subject of the data. Our purpose and intended use ofIthis information is to annually update our records and records of other governmental agencies required by law. If you refuse Ito supply the i formation,the application may not be issued. Applicant's Signature: Date: 27- / Last Updated: 08-09-2011