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SEP/14/2016/WED 09:55 AM Elder Jones Building FAR No, 952 854 4909 P, 002/003 City af Orono Builciing Permit Applicafiion for M�intenance 1 Reptacement 1 Remod�l — Resider�ti�l QNI,Y * (i.e.windows, doors, siding, re-roof, etc.�-NO STRUC7URAL EXPANSION) � Mailing Address: Permit number: ��rD "b �� 3 � �Q Pp Box 66 - Crystal Bay,MN 55323-0066 Date raceived: —� Streef Address: Recefved by: p y�, � 2750 Ke(ley Parkway Plan review fea: -�� � � Orono,MN 55356 (p qk 5�104�" Total Fee: �] t Main: 852-249-4600 Fax: 952-249-481fi www.ci.orono.mn.us � (T� � � al This appifcatlon form must be completed in full and all required infarmation must be submitted. Incomplete applications wili be retumed. (Please printJ GENERAL INFaRMAT[QN: !� Q � PO /� � ��'I �� Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Nome? ❑Yes ❑Na � !f yes,a specia/event permit is required w'�Police Department and City Council approval 60 days prior to the evant. Shutda bus servrce wi!!be requlred unless appl/cant demonstrates sufNclenf onslte parkJnq Is availabla. Non�ermitted avents wil!not 6e allowed. CONTRACTOR/APPUCANT INFORMATION� Name: State License# Qe11a Northlarad Expiration Date: Lead Cert�cation Number: 15300 25th Ave N. Ste 100 Expiration D�te: (for work on homes that i plytriouth,�N 55447 Phone: (cell) Lxc#BC645090 Pk�. 763/745-X400 �10e} Mailing Address: City: ZIP: Contact Person: q i� �y S- l. d y u Applicant i Contractor Homeowner tc�«�o�.� �mali and/or Fax: PROPERTY OWNER INFORMATIDN: Name: G14Y n e._,�ojM G S F'hone(day): s� � . �, Address: /3 9 4 P o r . ��y c. city: �o�� zi P: 5 5'3 G y �mail and/or Fax: PROJECT INFORMATION: Overall project description: TypQ of Projoct; Any earth movement may also require ❑Door(s) ❑Remodel ❑�ire Damage MCWD review&permits: ❑Re-roof,asphalt �]Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) � 15320 Minnetonka Blvd ❑Re-roof,cedar [f Restora4ion �Water Damage Minnatanka,MN 55345 ❑Re-roof,othe�(specify) ❑Siding ❑Other:(specify) Phona: 952-471-059a Fax: 95z-471-0682 Wlndow(s) www.minnehahacresk.ora Estimated Construction Valuation of Project(excludina land) $ �,/� S~s � APPLICANT ACKNOWLEDGEAAENT: • Agrees to provlde sll infarmation required or requested by the SulldEng Department; • Certifies that the information supplied is true and correct to the best of hismer knowledge. The applicant recognizes that they are solely responsible for submltting a complete appllcation befng aware tha4 upon failure to do so, the staff has no alterriative but ta reject it until it is comptete; • Some ar all of the information that you are asked to provide on this application Is classifled by State law as either private or canfidential. Private data is infomtation wFtich generally cannot be given to the public but can be given to the subject of the data. Confidentia)data is information which generally cannot be given to either Ehe public or the subject of the data. Our purposa and intended use of this informafion is to annually update our records and records of other governmental agencias required by law. If u refuse to su i the infouna ion,the a lication ma not be issued. Applicant's Signatur � Date: 7 ! � 3 r � 1+ Owner's Signature: Date: , Last Updated:January 2016