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- - City of Orono 1���fo <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O� Mailing Address: � — <br /> O PO Box 66 Permit number: � <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> ��, � 2750 Kelley Parkway Plan review fee: <br /> �' Orono, MN 55356 <br /> t�'�@S H��� � <br /> Total Fee: � ��O�, � <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: 2� �� J�(iJG�1('�. �fl.'�7A �l(/F� ���T �� <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 Council approval 60 days prior to the event. Shuttle bus s rvice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �p�� �tN.�✓1 CO�1�fRLt.G'[�btJ �(�1G . <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) b�Z r '?�a� -?��j�D (office) <br /> Mailing Address: �b. f30X 21 Q� MA��l.� 6l�oV� City: ZIP:`�'��� <br /> Contact Person: _i������� Applicant is: Contractor / Homeowner (CircleOne) <br /> Email and/or Fax: JpN-n/�j�,m�/ltSTi2hGT/DN �lYlA'�L . l,OM <br /> PROPERTY OWNER INFORMATION: � <br /> ►vame: 4�oR:cst� E MA2lC•`rnl /►'1lG�GiSN�C- <br /> Phone (day): GSZ_ ,�S-j ",,� 8�?� <br /> Address: 2�� 5���� W�.j� ���v�c City:�jN� �� ZIP: <br /> Email and/or Fax: —� � <br /> PROJECT INFORMATION: Overall project description: C�,L� � n/ N /V�W. <br /> Type of Project: Any earth moveme t may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8 permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt �Repair ❑ Storm Damage 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ —�'� <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 thi ' ation is to annu Ily update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I th in mation,the 'c ' n ma not be issued. <br /> Applicant's Signature� Date: ' �T ' �� <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />