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� # S � � <br /> City of Orono � ' � � �� <br /> ke � <br /> ' ' Building Permit Appiication for Maintenance / Renovation ?� <br /> ��: <br /> (windows, doors, siding, re-roof, etc.) �� <br /> �� <br /> Mailing Address: Permit number: oZ o � � -G 1 � ( J " <br /> �,L,�,� PO Box 66 � � <br /> 0 �, � Crystal Bay, MN 55323-0066 Date received: ��7 � <br /> I,� � �:,:� s, Street Address: Received by: Y' <br /> ��, ���'� �ti 2750 Kelley Parkway Plan review fee: � �� <br /> t9kE5Ho4� Orono, MN 55356 � <br /> Total Fee: �7� , �$ ' <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 /> p�� <br /> Incomplete applications will be returned. (Please print) �� <br /> GENERAL INFORMATION: �/ r � <br /> Job Site Address: ��� � �T�c1 b�c$ ��1` �� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No � <br /> If yes, a special event permit is required with Police Department and City Counci!approva/60 days prior to the event. Shuttle bus e � <br /> required unless applicant demonstrates sufficient on-site parking is avaifable. Non-permitted events will not be allowed. <br /> ' �� <br />� CONTRACTOR/APPLICANT IAIFORMATION: � <br />' ' Name: a �q � Fi c�rs ,�rL � <br /> State License# Z�3 �t.�S( Expiration Date: � / ��3 <br /> � <br /> Lead Certification Number: Expirafion Date: Z Z� ��� �r <br /> (for work on homes that were constructed prior to 1978 � � � <br /> Phone: � �-{_ p (office) 7(3 �2�- D� 03 �� (cell) � <br /> Maifing Address: �� 3p � -7� � �D� � City: �,�(A�,o F ��o�L ZIP: �-j6 S � <br /> Contact Person: �,4 Qo,, Applicant is: ontrac o / Homeowner (Circle One) ' <br /> � Email and/or Fax: � <br /> � <br /> PROPERTY OWNER INFORMATION: '' <br /> Name: C �.lT�`S �d���.S �� <br />_ Phone (day): � <br /> :� <br /> Address: City: ZIP: ' <br /> ;; <br /> Email and/or Fax �;; <br /> 'Nfi <br /> PROJECT INFORMATION: �� <br /> Type of Project: Any earth movement may require � <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: ; <br /> Minnehaha Creek Watershed District(MCWD) �? <br /> Re-roof, asphalt �air Q'�orm Damage 18202 Minnetonka Blvd '� <br /> [�'�e-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 '� <br /> Phone: 952-471-0590 � <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq �; <br /> Overall Project Description: �,a � <br /> _ Estimated Construction Valuation of Project (excluding iand) $ � 2� �� t� <br /> � �� <br /> �� <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 � <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternafive <br /> but to 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 ;� <br /> data. Confidential data is information which c,�n y cann t be given to either the public or the subject of the data. Our ��' <br /> purpose and intended use of this infor on is to annu "�update our records and �of other govemmental agencies � <br /> re uired b law. If ou refuse to the informatio , he a lication ma not ued. �' <br /> ApplicanYs Signature: Date: 9Q �o l� � <br /> ;.� <br /> Last Updated: 08-09-2011 <br />