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� - � City of Orono ' �� Building Permit Application for Maintenance / Replacement / Renovation $ �x (No structural expansion. Only windows, doors, siding, re-roof, etc.) �� � Mailing Address: Permit number. �3-'� x� �� PO Box 66 �;� � Crystal Bay, MN 55323-0066 Date received: �02 �� _ Received by: � b� '� � Street Address: < y� �' 2750 Kelley Parkway Plan review fee: � �,L Orono, MN 55356 � ��KESHO4 � 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: � � �t� C��a..+.�DDi� � � �� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No ,� If 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 ;i" required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR I APPUCANT INFORMATION: k& Name: �1��Ar1 �f�'tL�S[�� ; r-,< State license# Expiration Date: 5 Lead Certification Number. Expiration Date: Ca 'P (for work on homes that were constructed prior to 1978 "ss Phone: (cell) (office) r:� :;N Mailing Address: � � �jU 5��,�,�o,�� City: _ ZIP_ � Contact Person: }� .� Applicant is: Contractor / Homeowner �(Circle One) �� Email and/or Fax: �/@ �� -� a -�� y� �- � /. ;; � PROPERTY OWNER INFORMATION: � E• Name: �r�a.v� ��.� So►-� Phone (day): � � Address: �, �j(� j��u�� c�- City: �('pr�� ZIP: Email and/or Fax: �-� '�� PROJECT INFORMATION: Overall pro'ect description: =� Type of Project: Any earth movement may also require ; ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: `: Minnehaha Creek Watershed District(MCWD) �� ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage `; ,., 18202 Minnetonka Blvd ,�; ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �' ❑ Re-roof, other s eci Phone: 952-471-0590 ^� ( p fy) ❑ Siding ❑ Other: (specify) � Fax: 952-471-0682 � ❑Window(s) ��S � j--a�e-- www.minnehahacreek.orq {, Estimated Construction Valuation of Project(excluding land) $ 9S'GU� APPLICANT ACKNOWLEDGEMENT: ri� :�:,; • 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 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 subject of the data. Our purpose and ti� intended use of this information is to annually update our records and records of other governmental agencies required by law. If ou refuse to su I the information,the lication ma not be issued. � � � 9 � �; ApplicanYs Signature: � - �' -��F��ro,� Date: � ��v f ; �. � Owner's Signature: Date: $� � Last Updated: 03/06/2013 � ,, , k