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Jun. 15. 2016 2: 15PM No. 2722 P. 4 <br /> r ' City of Orono <br /> Building Permit Application for Maintenance/ Replacement/ Remodel RpsidOntiai"QNLY <br /> (i.e. g EXPANSION) <br /> • <br /> • <br /> windows, doors, siding, re-roof, etc.—NO STRUCTURAL <br /> Mailing Address: Permit number2 %i <br /> ----'44‘ixit0 - . . <br /> "l`Q{V POBox66 � <br /> Crystal Bay,MN 55323 0066 hale rece• ive r /4/j. <br /> Street Address: 'Receive by <br /> '''':11!'w-4k, <br /> 2750 Kelley Parkway Plan reQieW foe +,,.., <br /> G Orono,MN 55356 k ' 5 <br /> ��AE o�� Total Fee <br /> Main: 952-249-4600 FaX 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATIONI 0 r , <br /> Job Site Address: <br /> Will this bo a Parade of Homes, Rernodelers S owcase Home or other Display Home? ¶Yes rYplo <br /> • 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 <br /> required unless applicant demonstrates sufficient on-site parking Is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT I_NFORMATI II : • <br /> Name:' Y iC r • <br /> State License# .-• . I ' ' I. Expiration Date: 6 1 3( J 16 <br /> Lead Certification Number: h-1-2,10 ong. Expiration Date: • i a.o' <br /> (for work on'homes that were'constructed prior to 1978 <br /> Phone: (cell) (office) 9sg 11 (0-7 <br /> Mailing Address: oil L a, Cit _i1` ,a 13 <br /> Contact Person: jail , . i , , \e• • ' Applicant is: , ontract.r I Homeowner (circle one) <br /> Email and/or Fax: IA <br /> G c Ayf y-rt P- SCS(1P_\/‘ .,r b �^ G '" <br /> PROPERTY OWNER INFORMATIO • <br /> Name: t ,I <br /> Phone(day): a BuX . -i t <br /> Address: A Ill 1 • • _ N_ . , i,A l_e City: Onm(,, ZIP: <br /> Email and/or Fax: _ <br /> PROJECT INFORMATION: Overall project description:WI LaCtik 1 U' v 'o\ j V1 4 v"\o. () �' 1 l� <br /> Type of Project: Any earth movement may also equt i <br /> MCWD review&permits: <br /> ❑ Door(s) 0 Remodel . ❑Fire Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> El Re-roof,asphalt IDRepair ❑Storm Damage 9 15320 Minnetonka Blvd , <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(specify) El Siding ❑Other:(specify) Fax: 952471-0682 <br /> indow(s) 1 { .minne creek.or <br /> Estimated Construction aluatlon of Project(excluding land) $_ (.. qL7• U • . .— <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is complete; <br /> ■ Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is Information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is Information which generally cannot be given to either the public or the subject of the data, Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> fou refuse to sus'I th_,infonnati'n the a•.lication ma not be issued. <br /> Applicant's Signature: .r.. 1 Cr- 4 1 Date: C.f <br /> IS jk . <br /> Owner's Signature: _ • Date: <br /> • <br /> Last Updated:January 2015 <br />