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City of Orono Building Permit Application for Maintenance 1 Replacement / Remodel (i.e,. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION} OAT Mailing Address: Permit number. O� ! "J�`�(� S � 1 Y PO Box 66 � Crystal Bay, MN 55323-0066 Date received; � / Stieet Address: ,`�'`' y�, � 2750 Kelley Parkwa 0�,� � Plan review fee: .- �' Orono, MN 55356 ��k�SH04� 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 l�retumed. (Please print) GENERAL INFORMATION: Job Site Address: 2.�� Si�v{,rvit��d. nro�o M1� �535b Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home� Yes No If yes,a specia/event pem►it is iequiied w�h Police Depaitmerrt anci City Courta/appivva!60 days p►ior to the ev�ent. Shuttle bus servioe wiU be iequi►ed uMess applicant demonshates su�cie�on-site paiking is available. Norrpeimitted events will not be allowed. CONTRACTOR/AP LICAN FORMATION: ^ Name: • � � , State Lioense# Expiration Date: 3 3i �� Lead Certification Number: Expiration Date: (for work on homes that wene constructed prior to 7978 Phone: (cell) 1012- (085-��D I (office) 9rJ2-'-��5- ZOS� Mailing Address: ,� City: ;n,.ie.}�y�� ZIP: � 3c f$ Contact Person: � Applicant is: ontracto / Homeowner �c�.��o�� Email and/or Fax: PROPERTY OWNER INFORMATION: Name: �iq,1�t,-414r0� �YlO�I�On Phone(day): 12- V► Address: 2�?�p 5;�,,�c��;1,,,,, �, c�ty: Q�ohv z�P: 5535(� Email and/or Fax: PROJECT INFORMATION: Overall pro'ect description: ��.� w►��d�c. Type of Project: Any earth movement may also require ❑ Door(s) emodel ❑Fire Damage MCWD review�permits: Minnehaha Creek Watershed District MCVND ❑Re-roof,asphalt Repair ❑Storm Damage 18202 Minnetonka Blvd ( > ❑Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑Re-roof,other(specity) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora Estimated Construction Valuation of Project(excluding land) S 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 knovNedge. 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 confiderrtial. Private data is information which eneraly cannot be given to the public but can be given to the subject of the data. Confidenti which enera cannot be given to eithher the public or the subject of the data. Our purpose and intended`use of this 'nformati is t nnual upda ur records and records of other aovemmental agenae required by law. If ou refuse to orm "o e a tiom m �ot be issued. � �� ApplicanYs Signature: '� Date: � OwnePs Signature: Date: Last Updated:January 2015