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` City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O� Mailing Address: Permit number: �l (�' � 1 �j� <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: p� ' (��$ <br /> � � <br /> Street Address: Received by: � <br /> ti�, G� 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> tqKFS H 0�� <br /> Total Fee:� 2 Q(�. �� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �J U / <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: I (� <br /> Job Site Address: f �y� ^ `� VIOv'G �.►��t IJ ri�/L , <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 fhe event. Shuttle bus seivice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMAT ON: <br /> Name: 5 +C v-e ��s � 2� <br /> State License# (3 L 42 (o S'�� Expiration Date: <br /> 'S S 1 k$ <br /> Lead Certification Number: �Jq}� •¢ f� y8 5� - 1 Expiration Date: �-y� z� �� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �12- L2� - 5�5�0 (office) <br /> Mailing Address: City:�� y 4, ZIP: ��3 3 1 <br /> Contact Person: JG �s e, Applicant is: Contr�c� / Ho eowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �,�`�Cf �/c ��c Cj 0 V�S , <br /> Phone (day): �S�Z - -j c�S- c�c� <br /> Address: /�{���. �'j p,/'r ��1.�,t ��•-t v�C City:�cr� �c� ZIP: <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 MCWD review&permits: <br /> ( ) ❑ Fire Damage <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar �Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) .minnehahacreek.or <br /> Estimated Construction Valuation of Project (excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all inforrnation 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 an ually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I info ation,th a lication ma not be issued. <br /> ApplicanYs Signature: Date: 2 G <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />