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. Cit of Orono � �3 0� <br /> y � <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O� Mailing Address: Permit number: ow� - U�,2 — <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: — <br /> a a <br /> Street Address: Received by: <br /> ti�, G� 2750 Kelley Parkway Plan review fee: /.��p <br /> lqk�SHo�t�, Orono, MN 55356 a���j��d�7 <br /> Total Fee: <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: �j(,Q S ��`,(-1 t-L D-�'�J-e / <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> lf yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �y C� V,J,�,f�-�e�i �n.•�Q S' <br /> State License# ���Sc f� Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � 2-7� _� � (office) <br /> Mailing Address: _�2.�p V ��,�h,:.�.P�.�{j..�-y-� �� City:fy�,�n��j�,� ZIP: ,�[( <br /> Contact Person: ���� (�y y,����� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: /ccu mhl�,�S�r� ��c.a n-�S C.G"Yn <br /> PROPERTY OWNER INFORMATION: <br /> Name: -jA-y�E ,� �(�Y-� <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: � Vl l S� G'S.,Q �— <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Remodel ❑ Fire Damage <br /> MCWD review&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.orq <br /> Estimated Construction Valuation of Project (excluding land) $ �, Ofi7� <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 the' he a lication ma not be issued. <br /> ApplicanYs Signature: �- � Date: 3��2�g <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />