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, City of Orono � �J�" � � Building Permit Application for Maintenance / R novation (windows, do�rs, siding, re-roof, etc.) Mailing Address: Permit number: �O/a —�aS2� /g,�,� PO Box 66 Q , Q ��,J Crystal Bay, MN 55323-0066 Date received: (O'� �— a :� \'' �,� � Received by: S a � ✓��j� s, Sfreet Address: �'.�, ��p��ti�' \ 2750 Kelley Parkway Plan review fee: ��3 ' � l� �` � g �,\�� Orono, MN 55356 kESHO o,7D/� � DOSZ. -- Total Fee: Main: 952-249-4600 Fax: 952-249-4616 This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: �� a�� {r-�QQ� �.� . �QB�� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ❑ No lf yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/ PLICANT INFORMATION: Name: �jZT1.�E(�'S �{' �'IE'JI►� State License# (,�� Expiration Date: • � . Lead Certification Number: .. '� � Expiration Date: '�. �5 . � � (for work on homes that were constructed prior to 1978 Phone: � 'L• q�.Pl• S�Oq2 (office) q�j'Z• q't� • -��{''�' (ce��) Mailing Address: '�� ,Q,.�GL s . City: P(j� ZIP: Contact Person: �� y p Applicant is: Contrac / Homeowner (Circle One) Email and/or Fax: � �¢ ��,, 'p�S 1(�f�,� . O 1�•� PROPERTY OWNER INFORMAT N: Name: �jG 6"�L4 Phone(day): („Q�Z, • („�1 • (,P � O Address: �� .O.Q. �..1�jp� �L D C�tY��Gd 1�.�O ZIP:ss'3 5�O Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) �Remodel ❑ Fire Damage MCWD review 8�permits: Minnehaha Creek Watershed District(MCWD) ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re-roof,other(specify) ❑ Siding ❑Other: (specify) Fax: 952-471-0682 !'�� ❑Window(s) Overall Project Description: �L � �M L, : �' 4• L,Q(�I.!'�E„� Estimated Construction Valuation of Project(excluding land) $ C_��.�� 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 w�iich generally cannot be given to the public but can be given to the subject of the data. Confidential data is information whi�h;generally cannot be :given to either the public or the subject of the data. Our purpose and intended use of this i orrr�atio ' is to annually updat$ our records and records of other govemmental agencies re uired b law. If ou r fu s I in rmation,the a licati n ma not be issued. Applicant's Signature: :r' Date: Last Updated: 0&09-2011