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. � <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O�O Mailing Address: Permit number: �� Q�� <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: � S� <br /> Street Address: Received by: <br /> � � 2750 Kelle Parkwa <br /> �'�, G. Y Y Plan review fe � <br /> t �, Orono, MN 55356 � ��� �� <br /> qkESHOIt <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) ��� / 7J- ZZ <br /> GENERAL INFORMATION: �P <br /> Job Site Address: ��}�,� :��;��, �� � �.; j� �. <br /> Will this be a Parade of Homes, Remod�lers Showcase Home or other Display Home? ❑ Yes o <br /> If yes,a specral event permit is required with Pofice Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: Q <br /> Name: �,�r`.� � �' l(� '_ t�-�l c�-� <br /> State License# 3 �'j Expiration Date: .,�-�"=�S'� <br /> Lead Certification Number: _ 10 Q -r Expiration Date: j� j v j7 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) Z, � -�� (office) ,���� <br /> Mailing Address: ,S, �'j City: ZIP: �;f'�' <br /> Contact Person: � � C,�,^ Applicant is: ontracto', / Homeowner (Circle One) <br /> Email and/or Fax: ,_- ' ��. 76�._Z Z(v�- ti <br /> PROPERTY OWNER INFORMA ON: +i <br /> Name: ,�.v� �-�4�l.fbt.el� �- lTi'�l�,c�11� ��d� <br /> Phone (day): �( Z--��j(o� d(��S' <br /> Address: ]�IZd .S� � r c�ty:�rr.nfJ ziP: ,S-�S"_'r1l <br /> Email and/or Fax: �r-L(.�.��� ����,JDUt�ns��{. b�la .�t� <br /> PROJECT INFORMATION: Overall project de�^-` <br /> Type of Project: Any earth movement may also require <br /> oor(s) '—' , MCWD review&permits: <br /> ❑ Re-roof,as; � / ie Minnehaha Creek Watershed District(MCWD) <br /> � 18202 Minnetonka Blvd <br /> ❑ Re-roof,cea �� Q`�� � n �.��� � Deephaven, MN 55391 <br /> ❑ Re-roof,othe <br /> O �� Phone: 952-471-0590 <br /> `�,� � / Fax: 952-471-0682 <br /> �f ^ �r.t www.minnehahacreek.orq <br /> Estimated Cons � �q�P� • D ' $ Z..f�y � <br /> APPLICANT AC, <br /> � <br /> • Agrees to prov, Department; <br /> • Certifies that tha his/her knowledge. The applicant recognizes that they are <br /> solely responsib, �at upon failure to do so, the staff has no alternative but to <br /> reject it until it is� <br /> • Some or all of the _pplication is classified by State law as either private or <br /> confidential. Priva� ,, ue given to the public but can be given to the subject of the data. <br /> Confidential data is .,��t be given to either the public or the subject of the data. Our purpose and <br /> intended use of this te our records and records of other governmental agencies required by law. If <br /> ou refuse to su .,��� n a lic ' a not be issued. <br /> ApplicanYs Signature: � , - Date: / r �J � <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />