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City of Orono :�uilding Permit Application for Maintenance / Replacement / Remodel ' (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) �T Mailing Address: �" -- ��j VO PO Box 66 Permit number: ��-d J � � �� Crystal Bay, MN 55323-0066 Date received: � � _� .� Sfreet Address: Received by: y�, Gfi 2750 Kelley Parkway Plan review fee: �-'"' � Orono, MN 55356 � 9kE5 H 0�� Total Fee: r Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �" �, ` U� This application form must be completed in full and all required information must be submitted. /�Cj� Incomplete applications will be returned. (Please print) l GENERAL INFORMATION: l� �I� �� G� � ,�C Job Site Address � Will this be a Parade of Homes, Remodelers Showc e ome 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 e will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitfed events will not be allowed. CONTRACTOR/APse1 ANT I�FO�ATION: Name: �� State License# �bp`�� Expiration Date: 3'3I I )� Lead Certification Number: N fj�2�7J �2 Expiration Date: �.�� (for work on homes that were constructed prior fo 1978 Phone: -(r,� G�VJZ • Gj, -'� (office) �� , ' ��'(.P Mailing Address: ol/ City: 6},� �,t,�s yK ZIP:��jt�.l(� Contact Person: ��((, Applicant is: ontractor / Homeowner (Circle One) Email and/or Fax: �-Z.Gr22. PROPERTY OWNER INFORMATION: ( Name: ��,L�C-�I ��, � I��vl Phone(day): - - Address: 7 '�' �� City: �,� .�� C r ZIP: �,� � Email and/or Fax: PROJECT INFORMATION: Overall project description:�—Q�� '� �� UT ��V�t,r Type of Project: Any earth movement may also req ' e � oor(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: Re-roof,as halt Minnehaha Creek Watershed District(MCWD) p ❑ Repair ❑Storm Damage ❑ Re-roof,cedar 18202 Minnetonka Blvd ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof,other(specify) ❑Siding ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) w nehahacreek.or Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: • 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 gen rally cannot be given to the public but can be given to the subject of the data. � � � rpose an intended use of this inf e ann al p ate our records and records of other governmental agencies required by law. If ou refuse to sup l e i rma the lica n ot be issued. ApplicanYs Signature: Date: �v ' � Owner's Signature: Date: Last Updated:January 2015