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, • <br /> C:�-� <br /> City of Orono �l'�� ' <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �0�� Mailing Address: Perrnit number: ���'"���Z--- <br /> PO Box 66 � <br /> Crystal Bay, MN 55323-0066 Date received: " 6 '���/S� <br /> Street Address: Received by: �� <br /> y �" 2750 Kelle Parkwa <br /> �, �� Y Y Plan review fee: <br /> ' t,���sH���, Orono, MN 55356 <br /> Total Fee: ���. "3�� ` <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 applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �s�� v� /L� G � <br /> Will this be a Parade of omes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a specia/event permit is required with Police Department and City Council approval 60 days prior to the event Shuttle bus se ice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFOR�ATION: <br /> Name: (, p 1/ � (� <br /> State License# dp p Expiration Date: 3 / 7d� (o <br /> Lead Certification Number: �/� � 2 y� p — � Expiration Date: 3 2c9i <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (��2 _ 3�� — � ��� (office) ��Z^3� �� 2 O z G <br /> Mailing Address: 2 � �t,f� ST � 2 City: � S ZIP: �y v <br /> Contact Person: �p� Z � 2 �G L Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: /p�J Z,��v�/� r/U�Jvc1�c�� cr'D/�_ <br /> PROPERTY OWNER INFORMATION: �� ��/,� � <br /> Name: ,L G cJyvG�/� ��/a/�� � <br /> Phone(day): �2- -7�O — z S'�j � <br /> Address: — �tl �G � City: �c��v ZIP:�S�,3 , <br /> Email and/or Fax: �G 2 Cd <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <br /> Type 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 /> �J] Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(spectfy) ❑Siding �Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> `(�Window(s) www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) $ ! , oO6f � <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 informa' n is to annu Ily update our records and records of other govemmental agencies required by law. If <br /> ou refuse to su I the in rmation th lic ' ma not issued. <br /> ApplicanYs Signature: Date: ?d� <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />