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�'KE{ � .. g:;' Y )F,�y 3 !H..�^ ,�A .'�` . .. �i . . .. , .. '�'�� ; • City of Orono � Building Permit Application for Maintenance / Replacement / Renovation � (No structural expansion. Only windows, doors, siding, re-roof, etc.) ; �'� Mailing Address: Permit number: 4 �O�O PO Box 66 � � Crystal Bay, MN 55323-0066 Date received: ,��, ��: � Street Address: Received by: � ° 6�, ` 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: � ' �:,� ��„y,-��;. � 1-�L.--� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No 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. �:a CONTRACTOR/APPLICANT I F RMATION: �� �., Name: ��, . �� . ��,., � State License# C�j�i � � � Expiration Date: 3 C� Lead Certification Number: � _�" v,��;; � --� e- -�; � g � 3 �� y�� Expiration Date: � ; � � �-k (for work on homes that were constructed prior to` �1978 �` Phone: (cell) � I �. �•�l� -� 7� SSG' (office) (y l.� -�l �--`� �S�-' � Mailing Address: (�� f � � City:�y1� _�e�,� ZIP: S�3,5 � �� ;b�. Contact Person: � Applicant is: Contractor / Homeowner (Circle One) � Email and/or Fax: ��,� C� � ,,� b ' PROPERTY OWNER INFORMATION: '' - '' Name: .1 ��( l�i.�c�.�-�,��- Phone (day): _�� ,- � 7l r y�� _� L� Address: � � � �-t-ti,�-t�,-�,, ,2.,� L.�_ City: �%'Z�:.�� ZIP: S �'�3�; � Email and/or Fax: � l-� �_- PROJECT INFORMATION: Overall pro�ect description: �'��-c.4'L�2 � �'L' �«:.��-'�.��-� � %� Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel MCWD review&permits: � ❑ Fire Damage � _. � Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) kr-: 18202 Minnetonka Blvd �k ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 - Fax: 952-471-0682 �;, ❑Window(s) www.minnehahacreek.orq ` ,�;„�:: Estimated Construction Valuation of Project(excluding land) $ G�% - � 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 which generally cannot be given to the public but can be given to the subject of the data. � ' �' Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and `-a intended use of this information is to annually update our records and records of other governmental agencies required by law. If � ou refuse to su I the information,the a lication ma not be issued. ApplicanYs Signature: �= �� '��:-� � Date: �� .� � Owner's Signature: Date: � � ,; Last Updated: 03/06/2013 . � �