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. �: City of Orono 3 � � Building Permit Application for Maintenance / Renovation c�t�� (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: 04.,�,j�O PO Box 66 Crystal Bay, MN 55323-0066 Date received: .�, a �T y s, Street Address: Received by: ��n '� ti�' 2750+�elle Parkwa � � Y Y Plan review fee: t9kESH04'� Orono, MN 55356 � 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: � s.'; Job Site Address: ��.T �� S l�r ' t <'_ �, /� � _� < c� �„ Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No ,�.: If yes,a special event permif is required with Police Department 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 INFOR ATION: '� � �,� Name: - .�l�} � �F)-��, � State License# ; 3 -�,�� Expiration Date: ;��,�� 2 -�! Lead Certification Number: Expirafion Date: (for work on homes that were constructed prior to 1978 ; Phone: l `�>�. ��S � (office) C�- � � - �� h ��7 - 3 I l (cell) Mailing Address: �,� " �' `� c'/+ =- iz � l � �,� City: �L�,�r�w�¢,; f 1 ZIP: S S3C- � Contact Person: � `.0 Applicant is: ontractor / Homeowner (Circle ne) Email and/or Fax: PROPERTY OWNER INFORMATIO�: � �` Name: ��p�; y- -�� .� c�e Z � �> l . Phone (day): , Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require � ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: i Minnehaha Creek Watershed District(MCWD) � Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ��- ❑ Re-roof, other s eci Phone: 952-471-Q590 ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Overall Project Description: Estimated Construction Valuation of Project (excluding land) $ �' ,�� -� � t `�; APPLICANT ACKNOWLEDGEMENT: -`� • Agrees to provide all informafion 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 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 s purpose and intended use of this i ormation is to annually update our records and records of other governmental agencies re uired b law. If ou refu o su the informafion, the a licafion ma not be issued. 4 y • � � ApplicanYs Signature: � � ,`—� Date: � �� 1 ' � 1 Last Updated: 08-09-2011 '� ��