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City of Orono Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) A, Mailing Address: ��`VO PO Box 66 - � Permit number: �(�/ '7-dvo a Crystal Bay, MN 55323-0066�� Date received: /-/ �-/ �, � Sfreet Address: �� _Received b : 2 P � �'Yl S'�,` G� 2750 Kelley Parkway(/' �� p0 p,�j n review fee• - �kFSHo��. Orono, MN 55356 �C��L�, Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: � �� Q� /� lJ 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: �15 5 �►'vfy�p5 12D .H. Will this be a Parade of Homes, Remodelers Sho e Home or other Display Home? Yes No If yes, a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service wip be required un/ess applicant demonstrates sufficient on-site parking is available. Non permitted events will not be al/owed. CONTRACTOR/APPLICANT I ORMATIO Name: �� l� �N��d+� �. 'SNC . State License# 5�5� Expiration Date: 3� 31 . ��g Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) ��Z.�� , �.3,,�5 (office) Mailing Address: 3 �� i�,,,� �.E�.rs��s, Cit : ��r�p, ZIP: �53 Contact Person: Applicant i ontractor Homeowner (Circle One) Email and/or Fax: w�NL p�y�•�SN •C�v„� PROPERTY OWNER INFORMATION: Name: ��,,� �. �� Phone(day): �,-y , � �yy � Address: �ggc, A � • �j , CitY� ��a o ZIP: t�t;,3 z�(� � Email and/or Fax: PROJECT INFORMATION: Overall pro'ect descri tion: Type of Project: Any earth movement may also require ❑ Door(s) �] Remodel ❑ Fire Damage MCWD review 8 permits: ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) ❑ Re-roof,cedar ❑ Restoration 15320 Minnetonka Blvd ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 ❑Window(s) Fax: 952-471-0682 www.minnehahacreek ora Estimated Construction Valuation of Project(excluding land) $ l Sd,5 vo • 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 altemative 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 required by law. If ou refuse to su I the info at' ,the 'cation ma not be issued. ApplicanYs Signature: Date: _ � � i z - Zv �-� Owner's Signature: � Date: Last Updated:January 2016