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� <br /> f' <br /> . . . City of Orono � <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: aDl3-d/o��� � <br /> � PO Box 66 <br /> ��� <br /> � �� Crystal Bay, MN 55323-0066 Date received: �� ��-�� <br /> Street Address: Received by: <br />� � � � 2750 Kelley Parkway Plan review fee: � <br /> F �'` Orono, MN 55356 " <br /> `�'�ES H OR� <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: � C S r ��� � \ \ <br /> Job Site Address: ��� �1 � J <br /> Will this be a Parade of Homes, Remodelers S owcase Home or other Display Home? ❑ Yes o <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 ice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPL��A�NT I�OR TIQN:\�S, �� <br /> Name: �- �_ ��J <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) � �'i Z� �6�'�-2-�'/z (office) � <br /> ;; <br /> Mailing Address: .�q 5� -�nn_:� �� � City: �� ZIP: ���3 Z � �; <br />€`` Contact Person: `� <br /> 7"„ 4;�.r Applicant is� �ontractor�, / Homeowner (Circle One) <br /> �..:- -=----_: <br /> Email and/or Fax: L/'�pr�. �•z�O�,'�c��fS t3 ��/�h�c� � ��� <br />;',,,y <br /> � PROPERTY OWNER INFOR ATION: <br /> Name: 3�.� ��c ��: � <br /> Phone (day): ?bc�-Y��- 1� �: <br /> AddreSS: `"r � <br /> o1�6U S�iAc�l�ac� � _ City: ('x���co ZIP: '7�3}� ,. <br /> Email and/or Fax: '' <br /> ;: PROJECT INFORMATION: Overall pro�ect description: � <br /> Type of Project: Any earth movement may also require � <br /> MCWD review&permits: <br /> ,�; ❑ Door(s) Remodel ❑ Fire Damage `� <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 '�' <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (specify) ' <br /> Fax: 952-471-0682 �i <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 i+ <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 t m ' ,the a lication ma not be issued. "� <br /> ! ApplicanYs Signature: � Date: 3 ! <br />� �Zi�6 -ZU� <br /> e� <br /> f�, <br /> 1 :. <br /> Owner's Signature: Date: t§ <br />� ��� <br /> Last Updated:03/06/2013 <br />