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� City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O� MailingAddress: Permit number: � ���y <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 � Date received: <br /> 1 Received b <br /> � a <br /> Street Address: �� y� <br /> ti�, G� 275�Kelley Parkwa �' Plan review fee: � f{ <br /> lqkFSHO�� Orono, MN 55356 � ��t <br /> Total Fee: �s�' 7� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in fuli and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: � � �/� r <br /> Job Site Address: �.��.� � d r�^O ✓�'N �s�`S Y <br /> Will this be a Parade of Homes, Remodelers Showcase Ho e or other Display Home? Yes o <br /> lf 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 <br /> required unless applicant demonstrates sulficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone� (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: f <br /> Name: ��`�c.�C � :e! o,� I��i�t 'ti!1 <br /> Phone(day): �p 1 a $ I 1 � <br /> Address: J �S' o�,�r- �, City: �vn 0 ZIP: Ss�� <br /> Email and/or Fax: o �o ..y� <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> Door(s) ❑ Remodel ❑ Fire Damage <br /> MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding �Qther: (specify) Phone: 952-471-0590 <br /> � �' C Fax: 952-471-0682 <br /> ❑Window(s) rG� � C't �/'� > www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ , 0 0.0 <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 alternative 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 law as either private or <br /> confidential. Private data is information which generally 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 governmental agencies required by law. If <br /> ou refuse to su t the information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: <br /> Owner's Signature: Date: �� � <br /> Last Updated:January 2016 � ,���� ����(/�� � �G`� J m�� ���l.i <br /> G <br />