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City of Orono Building Permit Application for Maintenance/Replacement/Remodel - Residential ONLY (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) �O�O Mailing Address: Permit number: 1 �0� PO Box 66 Crystal Bay,MN 55323-0066 Date received: —�A�/� Street Address: Received by: � G� 2750 Kelley Parkway Plan review fee: `� Orono,MN 55356 ��kssHo��' �Wo'�" � Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. � Incomplete appllcations will be returned. (Please print)/��y�,yd� —�y�� GENERAL INFORMATION: ,L � Job Site Address: �'L s1TviQ�G,�i✓E �Q lil//��i9� �/1/ 5�.�� Wfll thls be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes If yes,a special event permit is required with Police Department and City Council approval 60 days prior fo the event. Shuttle bus seiw will be required un/ess applicant demonstrafes suf/icient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICAN INFORMA N: Name: /(/�.q�f I' �bfy+'d'a.�/ State License# Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that rr�neere constructed prior io 1978 Phone: (cell) �p/� �O/ 7S'Sr0 (office) MailingAddress: /y32 S' �%�.e J1 �e City: /� l,y �tP�neZIP: �,S3q/ Contact Person: Applicant is: Contrac or / eowner �c�roia o�e> Email and/or Fax: yJ,gjy:_ �0 �Sd� . �h � 9'!�4'i� !%ei'L�. PROPERTY OWNER INFORMAT ON: Name: /�/�k� ��•?,S a s-, Phone(day): �/L�D/ 7s'�-o Address: / L .�' � �� .c City: � �D,rro ZIP: S�3!�/ Email and/or Fax: �itR p hSd� . ��J "„�, . �!v..� PROJECT INFORMATION: Overall pro'ect description: Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑ Fire Damage MCWD review&permits: ❑Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑ Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 ❑ Re-roof,other(speclty) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 �-Vhindow(s) ,,� Z www.minnehahacreek.ora Estlmated Construction Valuatlon of Project(excluding land) $ �"v�• d� 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 generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generatly cannot be given to either the public or the subject of the data. Our purpose and intended use of t ' ' ion is to nually update our records and records of other governmental agencies required by law. If ou refuse t I the i n, e a IicaUon ma not be issued. <� Z0// "7 ApplicanYs Signatur : Date: Owner's Signature: Date: �� 7 Last Updated:January 2016