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"` Dec, 14, 2015 1 :52PM No, 0007 P. 2 <br /> . <br /> -" City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re,roof, etc. — NO STRUCTURAL EXPANSION) <br /> O Maifing Address: Permit numbar. �.s�� <br /> � �O PO Box 66 t <br /> Crystei Bay, MN 55323-0066. Date received: Z'"� —J <br /> � StreetAddress: �`s��j Received by. <br /> ��, G� 2750 Kelley Parkway ��. Plan review fee: <br /> {�R sHo�'� Orono,MN 5535$ '/ <br /> Total Fee� ,c,C� � � <br /> Main: 952-249-4600 Fax� 952-249-461fi v�o�v.ci.orono.mn.us "/ <br /> This application form must be completed in fufl and all required information must be submitted, <br /> Incomplete appfiCdtfotls wil!be returned. (Please p�nt) <br /> GENEIZAL INFORMATION: ��� �'- - 1�+��� �1� <br /> Job Site'Address: V�D{ ( <br /> Will this be a Parad�of Homes,Remodelers Showcase Home or other Display Home? Yes No <br /> (f yes,a specla/eu�a�t permit is required with Police DepaKlnent and City Council epprova/60 days prfor to the event, Shuft/e bus service wi!!be <br /> reguiled unless applicant demonst�^dt6s suffiCient on-site perking is avallab/e. Non-pemtitfed events will not be allowed. <br /> CONTI�ACTOR I APP ICANT INFORMATION: C'` <br /> �Name: �� ��If'�1+�� c7��i �� l�• <br /> State I,icense# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on 6omes that were construct�d�prior to 1978 p�. h��y 79�F <br /> Phone� (Cell) (p����-��i3 (offrce) . p � <br /> Mailing Address: � �.j , �� City: ��� ZIP: �j <br /> Contact Pel'sOn: Applicant is: on rd / Homeowner (Clrcle One) <br /> Email and/or Fax: (,Q(r� <br /> PRQP�R7Y OWNER INFORMATIO�: <br /> Name: �DhJ� ��A,�lt'y� <br /> Phone(day): � � � b 5 � <br /> Address: � �,�� �1�C City: �,�A(� ZIP: ��2' <br /> Email and/or Fax: 'Q D �, . �, <br /> PROJ�CT INFORMATION: Overall ro'ect description: <br /> Type of Pro]ect: Any earth movement may slso require <br /> ❑Door(s) O Remodel ❑Fire Damage <br /> MCWD review&permits: <br /> ❑Re-roof,�sphaft ❑Repair ❑Storm Damage Mlnnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> � p fi,� �� g � p �,� Phone� 952-471-0590 <br /> ❑ Re-roof,other 9 ec' �din ❑Other� s eci <br /> Fax 952�171-0862 <br /> ❑Window(s) www. � acreek.or <br /> Estimated Constru tlon Valuation�of�oiect�xcluding]and} $ ! <br /> n�w �sGr f��u � {�i u1 cnF Bc,�6, �5 ubr,('o� k�vl�j C�2 u�s-�_ . <br /> APPUCANT ACKNOWL�DGEMENT: /hL{, L �(i(,� <br /> • Agrees to provide all informafion required or requested by the Building Deparhnent; <br /> • Certifies that the information supplied is true and correet to the best of his/her knawledge. The applicant recognizes that they are <br /> solely responsible for subm�tting a complete applica6on 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 /> confidentiai. Private data is information which generally csnnot be given to the public but can be given#o the subject of the data. <br /> Confidentiel data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use ofthis information is to annual update our records and records of other govemmental agencies required by law. Ifi <br /> ou refuse to su I the inf h ma not be issued. <br /> Applicant's Signature: Date: �� � <br /> Owner's Signature; Date: <br /> Last Updeted:January 2015 <br />