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� City of Orono � � ��'�� � <br /> . , <br /> � Building Permit Application for Maintenance / Replacement / emodel <br /> , (�.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O�O Mailing Address: Permit number: o��/ =(�U <br /> PO Box 66 <br /> Crystal Bay, MN 55323-006 Date received: o�— <br /> � Street Address: I Received by: <br /> y � 2750 Kelley Parkway , ��� � 1�� <br /> Plan review fee: � 9 . g <br /> `�t� ��,� Orono, MN 55356 aU��P—�U7 a� <br /> KESH� <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: �S�O �ho.�. ��a. R�., <br /> Will this be a Parade of Homes, Remodelers Sho case Home or other Display Home? ❑ Yes No <br /> If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus s rvice will be <br /> required un/ess applicant demonstrates su�cient on-site parking is availab/e. Non permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Ue�o�e.�s 8�9$ L.L,� . <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: l�aor�-Fs 5098 �.�-.C_ <br /> Phone (day): ��a -3�3 -33a� <br /> Address: � lo I 1?`' fat�e. So. City: �..��k�n S Z�P: SS3y 3 <br /> Email and/or Fax: �\e.X� m'�a\��,g lo.ss . co r-� � <br /> PROJECT INFORMATION: Overall pro'ect description: �dd� �.rr�'�o�n« c�-acx.s i �-�a ;� <br /> Type of Project: Any earth movement may also requ e <br /> �Door(s) �Remodel ❑ Fire Damage <br /> MCWD review�permits: <br /> Minnehaha Creek Watershed District MCWD <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 15320 Minnetonka Blvd ( > <br /> ❑ Re-roof,cedar ❑ 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) $ C <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> 3 • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> Isolely 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 /> 1 <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 information,the a lication ma not be issued. <br /> ApplicanYs Signature: � Date: <br /> Owner's Signature: `�' � ��r' Date: � � �' <br /> Last Updated:January 2015 <br />