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� . - City of Orono <br /> �Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O� Mailing Address: Permit number: �-�"� � <br /> O PO Box 66 � <br /> Crystal Bay, MN 55323-006 / Date received: �-o?"07�� <br /> Street Address: Received by: <br /> r � 2750 Kelley Parkway � I 1„I �� Plan review fee: <br /> F <br /> �' Orono,MN 55356 `�' <br /> `qKESH��� �g�/ �� <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 appfications wilf be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: j� � � �'�'����L)�� p�-��� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No <br /> !f yes, a special event permit rs required with Pofice Department and City Council approva!60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil!not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: II� � �t-�'� h��r�,�s ✓�' OWT(�vJ � NL <br /> State License# G �j � Expiration Date: I <br /> Lead Certification Number: � I ( Expiration Date: (q <br /> (for work on homes that were constru ted prior to 1978 <br /> Phone: (cell) 1 � '7� � (office) <br /> Maifing Address: ( �t7s p v 10� (�' City: �(� (,,/{ L ZIP: <br /> Contact Person: J� � � Nj Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �p , y(�aS . 5 o�(S (����L � �G�- <br /> PROPERTY OWNER INFORM TION: <br /> Name: J d(= 5 C�4-1�IJ Q 0/l.(,C��- <br /> Phone (day): <br /> Address: L l-/ Q /L City: ��.� �d ZIP: <br /> Email and/or Fax: � �V�jGt-�-r�1 DII. ' ��►'d �t- . � <br /> PROJECT INFORMATION: Overall project description: <br /> iype of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&permits: <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 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 altemative 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 faw as either private or <br /> confidential. Private data is information which generalfy 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 govemmental agencies required by law. If <br /> ou refuse to su f e informa'o , h lication ma not be issued. <br /> AppficanYs Signature: Date: � Z � <br /> Owners Signature: Date: <br /> �ast Uodated: Q3/06/2013 <br />