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� � �. <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residentiai ONLY <br /> (i.e. windows, doors, siding, re-roaf, etc. — NO STRUCTURAL EXPANSION) <br /> A,. Mailing Address: <br /> ��`VO PO Box 66 Permit number. ZC?�[� ' <br /> Crystal Bay, MN 55323-0066 Date received: � '� "� 1 <br /> Received b <br /> � � Street Address: Y� <br /> ?�, ti� 2750 Kelley Parkway <br /> �.q��s��Rti�', Orono, MN 55356 Plan review fee: <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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: .r� �,,,�v( � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus s rvice will be <br /> required unless applicant demonstrates sufficient on-site parking is avai/able. Non-permrtted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Na m e: ��� ��n5 a�,w( �ew+�Ii�5 <br /> State License# C�Z C��I v 5� " Expiration Date: 3/31�(�( <br /> Lead Certification Number: ��T-a5o3y-a Expiration Date: c��aa�a� <br /> (for work on homes that were consfructed prior to 1978 <br /> Phone: (cell) (office) �j5a- �IS-7dd6 <br /> Mailing Address: y aa Exa.ls;.r 131� City:S{�. (.�,,;s )���1< ZIP: Ssy((, <br /> Contact Person: .�� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �(�,,�, (��4ro ���, �.�-, <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��,�� ��µJs`� <br /> Phone (day): 61�. - 85 C�- 5�y <br /> Address: �k, S���v.�o„� 1�( City� ���h`� ZIP� .�s33� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> � Re-roof, asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,cedar ❑ Restoration 15320 Minnetonka Blvd <br /> ❑Water Damage Minnetonka, MN 55345 <br /> ❑Re-roof, other(specify) ❑Siding ❑Other: (specify) Phone: 952-471-0590 <br /> ❑Window(s) Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 7� °' <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 suppl the information,the application ma not be issued. <br /> ApplicanYs Signature: Date: ����Ij7 <br /> / � v <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />