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� � <br /> " ` 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 /> �O�O Mailing Address: Permit number: ����"��d�' <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 9//—/ <br /> Streef Address: Received by: ��"/ '� <br /> y � 2750 Kelley Parkway Plan review fee: <br /> `�t L Orono,MN 55356 z �j�\ <br /> 1KFSHo�`�` Total Fee: ��J• / �` <br /> Main: 952-249�600 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 retur ed. (PI ase print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ''� � �vD t�' � /� � � �� � <br /> Will this be a Parade of Homes, Remo elers Show ase Home or other Displ y Home? Yes o <br /> If yes,a special event permit is required with Po/ice Department and City Council approva/60 days prior to the event. Shuttle bus s ice will be <br /> required unless applicant demonstrates s�cient on-site parking is avai/ab/e. Non permitted events will not be allow . <br /> CONTRACTOR/APPLI ANT I,�NFO�R�M;ATIO : p <br /> Name: -!�j OI« � � �D�J d L-L � <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes thaf were consbucted prior to 1978 <br /> Phone: (cell) _ � r 3 2 (office) ��Z — ��p �j � 3 <br /> Mailing Address: � (/�' City: � �/` ZIP: ''j <br /> Contact Person: Ap licant is: Contrac r omeowner ci«�o�� <br /> Email and/or Fax: � ' �t ' <br /> PROPERTY OWNER IN ORMATION: � � � <br /> Name: � � '' � <br /> Phone(day): .. — ?' Z � <br /> Address: � �Q City: � � ZIP: �3 � <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) emodel ❑ Fire Damage MCWD review 8 permits: <br /> ❑Re-roof,asphalt Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 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) $ <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�nnot be given to either the public or9he subject of��,rQuj�urpy se and <br /> intended use of this information is to annual u ate our records and records of other overnmental a ��f� law. If <br /> ou refuse to su I f rmation,t ication ma t be issued. <br /> ApplicanYs Signature: � Date: j` /� 1 � �u�/ <br /> Owner's Signature: Date: F ORONO <br /> Last Updated:January 20 <br />