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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> � (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �i A, Mailing Address: <br /> r�f VO PO Box 66 Permit number: �O<� —bI� <br /> Crystal Bay, MN 55323-0066 Date received: /d—o�7— �l,o <br /> �/��Street Address: Received by: � <br /> y�, � � 2750 Kelley Parkway Plan review fee: <br /> �qk�SHO��,�' �� Orono, MN 55356 4� <br /> �' Total Fee: � �1Y D� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: - � <br /> Job Site Address: ' (� �(� �/-k L � v,2'f <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o <br /> If yes, a specia/event permit is required with Po/ice Department and City Council approval 60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permifted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �U���i��t/ ��J� i���`-�2-5 /� L <br /> State License# �� �7(p'7 (o� Expiration Date: � - ��-�� <br /> Lead Certification Number: " �R--r- � ���.���.� � Expiration Date: -�,-- ,� - � � <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) _ �(pS � (office) �,q�-� �� <br /> MailingAddress: ��c{S ���,�,�,.i,�� ���G,�� City: — �- ZIP: <br /> Contact Person: �2i�.� Applicant is: Contractor / Homeowner <br /> (Circle One) <br /> Email and/or Fax: ��C��� �L i-�- S 7�.. L� �,� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �r�13/3 d— ��/kt/��- �i U2S C��Co <br /> Phone (day): <br /> Address: �rj ����,4 -(...cy1�1 L�(�tJ✓�` Cit '-'� <br /> �` Y� L.�� �-,��' ZIP� �5 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) � Remodel ❑ Fire Damage MCWD review 8 permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project (excluding land) $_ ��(�DOy <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I t e information, e a lication ma not be issued. <br /> ApplicanYs Signature: ���,%� /,/ Date: r�—��t'r� � <br /> r <br /> Owner's Signature: �� Date: <br /> Last Updated:January 2016 <br />