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JUN/02/2017/FRI 01 :39 PM Elder Jones Building FAX No, 952 854 4909 P, 002 � � . � City of Orona Building Permit Application for Maintenance !Replacement!Remodel-�ResidentiaN ONI.Y (i.e.windows, doora, siding, re-roof, etc.—NO STRUCTURAt EXPANSfON} �O�}O Msiling Address: Permit number. �/ -d� 1 y PO eox 66 Crystal 6ay,MN 55323-OD66 ba#e received: 6'J�-�7 Street Address: Received by: y�, Gti� 2750 Kelley Parkway Plan review Fee: l,�x'psHo�.� Orona,MN 55356 Tatal Fee: 9� � I+Aain: 952-249-4600 Frvc: 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) G�N�RAL INFORMATION: Job Site Address: 1��t� �1 �.r k �'r. Will thls be a Parade of Homes,Remodelers Showcase Flome o�other Display Hvme? Yes No !f yes,a speclal evorK permlt Is requlr�a�wlth Pollca Dapartmsnt and Cfry CouncN app�ova!BO days prioi to fhe event. Shutt�e bus aervice will be requlred unf�ss appllcant demonsbates sufflclettt on-slte perkfnp Is available. Non-permitted evenPs wi!!not ba eRowed. CONTRAf�.... . �..... .,........�. ,,.,...,....�.. Name: ��r1a Northland 5tate Lice 15300 25t�i.A.ve�T. Ste 100 Expiration Date: � � Lead Certi ��Quth,MN 55447 ��S 1� Z-1 Expiration Date: Phone�/ �xc#BC645090 Ph. 763/7�45-1400 r8 (office)��Z-'��{S�adS7 ��.u.� Maifing Address: City: ZIP: Corrtact Person: AppNcant fs: ontraotar / Homeowner (ClrclaOne) �maif and/or Fax� PR�PERTY OWNER INFORMATIO : Name: �/1��A �1(� �trY1L?� Phone(day): G� Z-1.�,7�r�'�q�� Address: City: ZIF': Email and/or Fax: PROJEC7INFORMATION: Overall project descnption: Type vf ProJect: Any earth movement may also requir� ❑boor(s) ❑Remodel ❑Fire Damage IIMCWb review&permlts: ❑F2e�roof,asphalt �Repair ❑Storm 17amage Minnehaha Greek Watershed Dfstrict(MCWD) 15320 Minnetonka 81vd ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 �Re-roof,other(specify) ❑S(ding []Other:(spec�fy) Phone: 952-471-os90 Fax: 952-471-0662 �-Window(s) � www.minnehahacreek.ora Estimated Construction Valuation of Project(exclading land) � �— APPLICANT ACKPIOVII��DG�M�NT: • Agraes to provide all iriformatian required or requested by the euilding Departmant; • Certifies fhat the information suppfied is true and correct to the besf of his/her knowledge. The applicant recognizes ttlat they are solely responsible for submltUng a complete appllcatlon being aware that upon faflure to do so,the staff has no altemative but to reject it unti!it is complete; • Some or all of the information that you are asked to provide on this application is classified by 5tate law as elther prfvate or confldentlal. Prlvete data Is Ir�formatlon whlch generally cannot be glven to the publlc but can be glven to the subject of the data. Confidenti�t data is informatian which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of thls Information fs to annually updete our records and records of other governmental agencles required by law. If ou refuse to su I the information the I'cation ma not be issued. Applicant's Signature: � Date: ��y�� Owner's Signature: _ Date: l.ast Updated;January 2U16