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� . City of Orono <br /> � -Building Permit Application for Maintenance / Replacement / Remodei <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> O Mailing Address: Permit number: c���S'" �/VJ � <br /> � �O PO Box 66 ,/ <br /> Crystal Bay, MN 55323-0066 Date received: 7—'���S <br /> Street Address: Received by: <br /> y ` 2750 Kelley Parkway Plan review fee: `�' ����� <br /> � G <br /> lqK�SHo��, Orono, MN 55356 a,�� �_�j�3-7 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <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: �� / � /� 3 <br /> Job Site Address: (p � , G�(� i/Lr ��' / <br /> Will this be a Parade of Homes, Remodelers Showcase Horrye,�pr other Display Home? ❑ Yes o <br /> If yes, a special event permit is required with Police Department and City Co� �c 1 approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parki�� vailable. Non-permitted events will not be allowed. <br /> CONTRACTOR l APPLICANT INFORMATION: � �I'� <br /> Name: -f � �, ��Gf_e.v <br /> State License# � �� 2 Expiration Date: ��� 3� � z�.,� � <br /> Lead Certification Number: �y-�}�_ �. � 2 y Z�2— / , Expiration Date: G / � s � ��, ,�rj <br /> (for work on homes that were constructed prior to 1978 ' J <br /> Phone: (cell) (� Z 3 ��.: Z � (office) <br /> Mailing Address: j �j��/ � ��� ��j City: � y , 5 v,`� ZIP: S,s� 33 <br /> Contact Person: ..���,,� r�� r Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: `����� ��S � �,,��,�,�,� <br /> PROPERTY OWNER INFORMATION: <br /> Name: S,-I l��? �'% <br /> Phone (day): `7(0 3 2 3z.z > >,,�� S-s <br /> Address: 7Z�� C�- r S w y _ City: S ��.,��, ZIP: � � <br /> Email and/or Fax: C m��q h v�„� y Z � z��r�a���:-�- <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Ly'Remodel ❑ Fire Damage MCWD review&permits: <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(sr�iecify) ❑ Siding ❑ Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ,�` ❑Window(s) www.minnehahacreek.org <br /> Estimated � nstruction Valuation of Project (excluding land) $ SS;C�c�' <br /> APPLIC�4NT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information 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 annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the information,the a lication ma not be issued. <br /> Applicant's Signature: Date: t/f i�/S <br /> Owner's Signature: �---,',�171,�'I Date: �//fi <br /> Last Updated:January 2015 <br />