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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) A, Mailing Address: �� .� �0�VO PO Box 66 Permit number. Crystal Bay, MN 55323-0066 Date received: � Streef Address: Received by: � y�, ��' 2750 Kelley Parkway Plan review fee: � Orono,MN 55356 �A'CES H OQ`� � /_O�V� Total Fee: ��J 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 applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: U S �e 1� C1 Y (�(� �S Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes o If yes,a spec/al event permit Is required with PoNce Department and City Councll approval 60 days prror to the event. Shuttle bus se c wlfl be requ/red unless appflcant demonstrates su�cient on-s/te parking!s avallable. Non-pa�tnitfed events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: State License# C lpC�c�� Expiration Date: Lead Certification Number: (v�`A�.F �5 � 'lS- � Expiration Date: I n I� ..s,�r�,.. (for work on homes that were consfructed prlor to 1978 Phone: (cell) (office) �Z . Mailing Address: City: ZIP: S Contact Person: G Applicant is: ontra Homeowner �ci►�ie o�a� Email and/or Fax: ��L..�l I 4�� L�J`Q �� PROPERTY OWNER INFORMATION: Name; � a�l 4. ��(1 l�l f-�� Phone(day): Address: ZO—1 0 S V1 G I�P �,fin n p�, �Yl1v��) , Nl,nl c�cy: C�I(�1Y2� ziP: .SC'�q� Email and/or Fax: PROJECT INFORMATION: Overall ro'ect descri tion: — Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage MCWD revlew 8�permlts: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 Phone: 952-471-0590 ' Re-roof,other(spectfy) ❑Siding ❑Other:(speafy) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora Estlmated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all Inforrnation required or requested by the Building Depa�tment; • 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 applicatlon 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 eithe�private or confidentlal. Private data is information which generally cannot be given to the publlc but can be given to the subject of the data. Confidential data is information which generally cannot be glven to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies requlred by law. If ou refuse to su I the informatlon the a lication ma not be issued. �J� �l�.. ' ��) ��_ Applicant's Signature: ��o ��,�� Date: C �, Owner's Signature: Date: Last Updated:January 2016