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- • - City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) � �O A? Mailing Address: Permit number. �/ "' �VO PO Box 66 Crystal Bay,MN 55323-0066 Date received: 7— �-�-— Street Address: Received by: ' ti�, � 2750 Kelley Parkway Pian review fee: l,�KESHO�t�,�' Orono,MN 55356 /�/ w _ Total Fee: �o�� 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 wiii be retumed. (P/ease print) GENERAL INFORMATION: 3 � � � O 1 t `� �D Job Site Address: N'�' Will this be a Parade of Homes,Remodelers Showcase Home or other Dlsplay Home? Yes No If yes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shultle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non peimitted evenis wil!not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: � �-f.2, ZL� State License# '1 Expiration Date: 3—3 � — �� Lead Certification Number: (�IIA� — F �3 O(� —� Expiration Date: �- -a� - � (for work on homes that were constructed prlor to l978 Phone: (cell) (p��—3(p�—(�� l� (office) Mailing Address: , f�� City: �p�,,'� /�(Lt"` ZIP: ��(�fo Contact Person: �h�� 5�,�,t� Applicant is: tractor / Homeowner �a�e a,e� Email and/or Fax. ��.y4(��j,4 F�FfL,s � �,�.��Y�..�� PROPERTY OWNER INFORMATION: Name: _f J�)►t�C�. lr4iC.�i C h4�L.. Phone(day): _� --1va.-$13— 59ay Address: I''�'1 J� �rS.� �Jp�fJ�— (L� City: [�fj�t'j�..� ZIP: �3�0�'(, Email and/or Fax: PROJECT INFORMATION: Overatl ro'ect descri tion: Type of Project: My earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review�permlts: �Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed DisUict(MCWD) ❑Re-roof,cedar 18202 Minnetonka Blvd ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(speclty) ❑Siding ❑pther:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.or4 Estimated Construction Valuation of Project(excluding land) S (� � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Departmerrt; • Certifies that the information supplied is Uue and correct to the best of his/her knowledge. The applicant recogn¢es that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative 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 give�to the subject of the data. Confidential data is information which generally cannot be given to either the public o�the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other govemmental agencies required by law. If ou r�efuse to su I the info 'on,the a li tion ma t be issued. ApplicanYs Signature: Date: __� �`�� y Owner's Signature: Date: Last Updated:03/06/2013