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. . . . ��. � ' �� ' � . � � � y� City of Orono �� . � � Building Permit Application for Maintenance / Renovation �' „�`� � (windows, doors, siding, re-roof, etc.) `�� :�: Mailing Address: �; �,0,�. PO Box 66 Permit number: � � �, 0 Crystal Bay, MN 55323-0066 Date received: � s; a � �� , Street Address: Received by: � >` �',�c, t 6,�p„ �� 2750 Kelley Parkway Plan review fee: � L9g o4� Orono, MN 55356 �..:, ESH 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 INFORMATION: ~. Job Site Address: / 3� O j�CJ f �j�� ' � �.� � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No :� :�;� If yes, a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be � required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. , . ;,=�.� CONTRACTOR/APPLICA T INFORMATION: , � Name: � �..5/�y /� n� � �f�i�,�� r � State License# �}v,� �j-y$c7 Expiration Date: �o/� �<, Lead Certification Number: Expiration Date: '�` �; (for work on homes that were constructed prior to 1978 �; Phone: '�Co�-S7 y�f�,3 j (office) (cell) �° Mailin Address: i! Cit % � 9 / 7dv / `3c7 ,0/ � Y� /'')Z¢t G+�-� ZIP: .S��3�`/ ;� �� Contact Person: �� Q.�y„'��j C 21�'/>:j.,-� Applicant is: Contractor / Homeowner (Circle One) �� Email and/or Fax: 7(,3- yy�_��0 3� i � �� PROPERTY OWNER INFORMATION: Name: 1��:�� T�� Phone (day): ��C-r/�.� (Q k 3� " �° Address: (3 � -e✓� ,�/o,,1t C ,.,/' City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review& ermits: ❑ Door(s) ❑ Remodel ❑ Fire Damage P Minnehaha Creek Watershed District(MCWD) �Re-roof, asphalt ❑ Repair [p�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) www.minnehahacreek.orq �" �,� �Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ �O, o�� ;�; APPLICANT ACKNOWLEDGEMENT: �� ,� • Agrees to provide all information required or requested by the Building Department; F�j • 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 sub�ect of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies � � re uired b law. If ou refuse to su I the information,the a lication ma not be issued. �f� � �_� s� � ApplicanYs Signature: � Date: �` <�G i�� 1 Last Updated: 08-09-2011 � �i� ..�u �� _ _ _ . _ __ .