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City of Orono � � uilding Permit Appl�cation for Maintenance / Replacement / Remodel � (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) ��' � A,. Mailing Address: Permit number: `� �Ol yO PO Box 66 Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: y G� 2750 Kelley Parkway Plan review fee: � Orono, MN 55356 `qKFSH�� 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 applications will be returned. (Please print) GENERAL INFORMATION: � Job Site Address: �-{`�'J ��C:l'��e� '� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes o If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT�ORMATION: Name: �� -�� . State License # p��53�_� Expiration Date: � 3i(�� Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) i�ld-�J.1-�{�� (office) �p�{/K� Mailing Address: �-k� ,� �_ City: ZIP: Contact Person: � ' Applicant is: Contractor / Homeowner (Circle One) Email and/or Fax: ��,,�:.��(�M�S�,��„a � �,,.` PROPERTY OWNER INFORMATION: Name: Phone (day): �-Z_'��V _ �t{yy Address: 3�� (�,�� City: ��`tgt�"� ZIP: �3� t Email and/or Fax: �„`��, �e,�� C,,�v�a� � �c�,v� PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 �te-roof,other(specify) ❑ Siding ❑ Other:(specify) Phone: 952-471-0590 l�p�,� Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project (excluding land) $ �q i�c'z= - " 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 wh' e ot be given to the public but can be given to the subject of the data. Confiden al is information which g erally annot be e to either the public or the subject of the data. Our purpose and intended se of t 's information is to a ually pdate�our re ds and records of other governmental agencies required by law. If ou refus to su the information, e e issued. Applicant's Signat . ��Z L� Date: ��U�c�ct� Owner's Signature: Date: Last Updated:January 2015