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� � Cit of Orono �'�� <br /> . Y -- <br /> B;�il�i�ng Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> n O� Mailing Address: Permit number: �C'/ - 6 �� �,� <br /> L O PO Box 66 I / <br /> Crystal Bay, MN 55323-0066 Date received: 7'�� " ��t <br /> � Street Address: � n � Received by: �6 <br /> 5� � 2750 Kelle Parkwa � <br /> � Y Y � ►1`�I Plan reviewfee: � 3�3- 2-�-� <br /> � G <br /> ��'�ESH��� Orono, MN 55356 J a 61 �/.- UO �I �1 <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: � _, � C � f <br /> Job Site Address: �`�� � ��,�;�� _ �-�i;y�,�,{,r�� �� ��}-� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or o r Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus servrce will 6e <br /> required unless applicanf demonstrates sufficient on-site parking is available. Non-permitted events will nof be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �.;�:r'1rtE. ,\ ' <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFOR�IAATION: .__� n <br /> Name: -� �_�� � --� ./ -, <br /> � �� 1'� <br /> Phone (day): -, ;- . ' , .�} Zj <br /> Address: LCiu �� � �``Z— Cit��.%CL� 1c,�_�f�_ ZIP: ��-�"1, � <br /> Email and/or Fax: � 1 � � c- u _ N-ti, <br /> � <br /> PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: � Any earth movement may also require <br /> � �,�'��`������' MCWD review&permits: <br /> ❑ Door(s) ,�emodel ����-� b � Fire Damage <br /> ❑ Re-roof,asphalt /�Repair�''� `� � ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> • 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ .� - <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information suppfied is true and correct to the b of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being a e 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 informatio � to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the info ,t lication ma not be issued. <br /> ApplicanYs Signature: -- Date: �� � <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />