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r,. �: . . City of Orono ` Building Permit Application for Maintenance / Replacement / Renovation '�� `y �, (No structural expansion. Only windows, doors, siding, re-roof, etc.) � �� MailingAddress: Permitnumber: 0�� �D�O PO Box 66 _ � � Crystal Bay, MN 55323-0066 Date received: � � ' Received by: �� - Street Address: � � �� y �' 2750 Kelle Parkwa ; F ti Y Y Plan review fee: � • �,�' Orono, MN 55356 '� � qkESHO 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: ��SC' �--'�� (� �-��d1� �-�a�� Will this be a Parade of Homes, Remode rs Showcase Home o ther Display Home? ❑ Yes ❑ No �` If yes,a special event permit is required with Police Department and City Council approva/60 days pnor to the event. Shuttle bus service will be s- required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ,,,. '. �' CONTRACTOR/APPLICANT INFORMATION: '' Name: „e a�\ � �� ,v� �ti^c,��,� �� � , State License# ��,��{��1j � Expiration Date: � ~k Lead Certification Number. �� Expiration Date: �"` (for work on homes that were constructed prig�to 1978 ; Phone: (cell) �p�- �?�'i(,o�p/o2�} (office) + ' Mailing Address: %3a`7j a6-�' ,vuJ City: .'v1P�— ZIP: r`j'S 3J2p � �,. Contact Person: ��i+ Applicant is: Contractor Homeowner (Circle One) �� �� Email and/or Fax: � � � fl" PROPERTY OWNER INFORMATION: � ►vame: 5��i �ck.,��[��t � Phone (day): '7�'� -�{'� g-CetQp� '��, Address: o2�{SC� C_•{�.� �1 lQ c�ty:�n�,�,� ziP: �;' ,� Email and/or Fax. ' `;� PROJECT INFORMATION: Overall pro�ect description: � Type of Project: Any earth movement may also require � � ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: �` ¢t �Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) } 18202 Minnetonka Blvd ❑ 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) $ �C�a � K� ,��, �� '' 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 ctassified by State law as either private or �' r�� confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. a� Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and .;� intended use of this information is to annually update our records and records of other governmental agencies required by law. If �a ou refuse to su I the inform tion,the a lication ma not be issued. � ApplicanYs Signature: � �ate: 7`q��,3 x � Owner's Signature: Date: � Last Updated:03/06/2013 ;