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Jun. 15. 2016 2: 15PM No. 2722 P. 4 r ' City of Orono Building Permit Application for Maintenance/ Replacement/ Remodel RpsidOntiai"QNLY (i.e. g EXPANSION) • • windows, doors, siding, re-roof, etc.—NO STRUCTURAL Mailing Address: Permit number2 %i ----'44‘ixit0 - . . "l`Q{V POBox66 � Crystal Bay,MN 55323 0066 hale rece• ive r /4/j. Street Address: 'Receive by '''':11!'w-4k, 2750 Kelley Parkway Plan reQieW foe +,,.., G Orono,MN 55356 k ' 5 ��AE o�� 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 INFORMATIONI 0 r , Job Site Address: Will this bo a Parade of Homes, Rernodelers S owcase Home or other Display Home? ¶Yes rYplo • If yes,a special event permit is required with Police Department and City Council approval eo days prior to the event. Shuffle bus service will be required unless applicant demonstrates sufficient on-site parking Is available. Non permitted events will not be allowed. CONTRACTOR/APPLICANT I_NFORMATI II : • Name:' Y iC r • State License# .-• . I ' ' I. Expiration Date: 6 1 3( J 16 Lead Certification Number: h-1-2,10 ong. Expiration Date: • i a.o' (for work on'homes that were'constructed prior to 1978 Phone: (cell) (office) 9sg 11 (0-7 Mailing Address: oil L a, Cit _i1` ,a 13 Contact Person: jail , . i , , \e• • ' Applicant is: , ontract.r I Homeowner (circle one) Email and/or Fax: IA G c Ayf y-rt P- SCS(1P_\/‘ .,r b �^ G '" PROPERTY OWNER INFORMATIO • Name: t ,I Phone(day): a BuX . -i t Address: A Ill 1 • • _ N_ . , i,A l_e City: Onm(,, ZIP: Email and/or Fax: _ PROJECT INFORMATION: Overall project description:WI LaCtik 1 U' v 'o\ j V1 4 v"\o. () �' 1 l� Type of Project: Any earth movement may also equt i MCWD review&permits: ❑ Door(s) 0 Remodel . ❑Fire Damage Minnehaha Creek Watershed District(MCWD) El Re-roof,asphalt IDRepair ❑Storm Damage 9 15320 Minnetonka Blvd , ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 Phone: 952-471-0590 ❑Re-roof,other(specify) El Siding ❑Other:(specify) Fax: 952471-0682 indow(s) 1 { .minne creek.or Estimated Construction aluatlon of Project(excluding land) $_ (.. qL7• U • . .— 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 fou refuse to sus'I th_,infonnati'n the a•.lication ma not be issued. Applicant's Signature: .r.. 1 Cr- 4 1 Date: C.f IS jk . Owner's Signature: _ • Date: • Last Updated:January 2015