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' . . , . . ��. "'r t.�":� . � � City of Orono t �� ,k Building Permit Application for Maintenance / Renovation � 4; (windows, doors, siding, re-roof, etc.) / ^� � Mailing Address: Permit number: ��' �G 4�/ � �.,0,� PO Box 66 . �� O �� O Crystal Bay, MN 55323-0066 Date received: a � >>� a, Streef Address: Received by: ¢ �.z�� ��,s, ' �ti 2750 Kelley Parkway Plan review fee: L9kESH�4� Orono, MN 55356 Total Fee: �03, a7 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: � �C7� � � � '�p - Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No If yes,a special event permit rs required with Polrce Departmenf and City Counci!approva/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. CONTRACTOR/APPLICANT INFORMATION: Name: �L` � 3N� >' 7�' State License# Expiration Date: � Lead Certification Number: Expiration Date: �� (for work on homes thaf were constructed prior to ?978 �? Phone: ��'��.,��_y=�,�C� (office) (cell) �� Mailing Address: r� ��, / City:�`� G',�G` �= ZIP: S S- / �_ Co ct Person: ` C�N C f��TE�' Applicant is: ontractor� / Homeowner (Circle One) �. Email nd/or Fax: � , c��,,, T:..":, `` PROPERTY OWNER INFORMATION: Name: �n�,��,� ' �� , _ Phone (day): `� ° .� �' _ '',2Z.G � Address: � _ 30� � C' � City ��,��G ZIP: ,� Email and/or Fax E� PROJECT INFORMATION: K�; Type of Project: Any earth movement may require ,� ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: �� Minnehaha Creek Watershed District(MCWD) `� " ` �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deep haven, M N 55391 ' ❑ Re-roof, other s eci Phone: 952-471-0590 ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 � ❑Window(s) www.minnehahacreek.orq �' Overall Project Description: � �_- Estimated Construction Valuation of Project (excluding land) $ f � S'c1� �, � � �� 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 alternafive 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 intended use of this information is to annually update our records and records of other governmental agencies re uired b law. If ou refuse to su f the information,the a lication ma not be issued. ;� � AppficanYs Signature: � Date: ��/ �O// � jJ Last Updated: 08-Q9-2011 � ,,. ;9� :�