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. ��'t�"' �,p.L'� - .,"� x. ' �`+ . - City of Orono J � �� :; t Building Permit Application for Maintenance / Renovation �� = T� (windows, doors, siding, re-roof, etc.) , � Mailing Address: Permit number: v -. � �7 �� �,0,� PO Box 66 :� O � 0 Crystal Bay, MN 55323-0066 Date received: �_ ��J -1 '? �,�, a €r � Received b � � � �� Street Address: Y� �_. .� �,ti 2750 Kelley Parkway Plan review fe : � r9kESH�g'/ Orono, MN 55356 � -- ��, �S" � '--� 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. �L "� Incomplete applications will be returned. (Please print) '� ` " GENERAL INFORMATION: C � �� Job Site Address: �o�J c�L�SSc x I�C� � § ; Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No � � lf es,a s ecial event ermit is re uired wifh Police De artment and Cit Council a �� Y P p q p y pproval 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 INFORMATION: �.� Name: �G�.$i� ��72cT� �� �.� State License# ��,3 /�?� Expiration Date: .3 3� �v � �.; �� Lead Certification Number. Expiration Date: � �;: � (for work on homes that were constructed prior to 1978 �� Phone: 7(0 3 - 7 '—� ov (office) (cell � �<-° Mailing Address: T/ �-- ��,��r;�„f� �'�{-- Cit �yj (,E, C,,t1, ZIP: ) � y � S��z Contact Person: �01�,�} Applicant is: Contra t r / Homeowner (Circle One) � :�' Email and/or Fax: � �.. k$+ PROPERTY OWNER INFORMATION: � ,' Name: ��C=72�fi'�21�r � �°�� Phone (day): �E �< Address: r� � �.. �� s,S'�S"C�Z .� CitY� ��C>� v ZIP: �' �� � Email and/or Fax �, t�: �' 4� PROJECT INFORMATION: Type of Project: Any earth movement may require �. ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: ;� �, Minnehaha Creek Watershed District(MCWD) ^ [�Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd '" ,�� i3 ❑ Re-roof, cedar ❑ Restoration Deephaven, MN 55391 � �,; ❑Water Damage Phone: 952-471-0590 ,- ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 ,: � ~ ❑Window(s) www.minnehahacreek.orq r�' ��' Overall Project Description: ' f L f E� �.: -�'1-2-�� / oo,�- ��.. Estimated Construction Valuation of Project (excluding land) $ �c� � _ �,a �� APPLICANT ACKNOWLEDGEMENT: �- • Agrees to provide all information required or requested by the Building Department; r � • 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; i�F;.. i:, ' • 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 � re uired b law. If ou r o su I the i €ormation, the a lication ma not be issued. ":,t:� I k�^� �°' Applicant's Signature: � - Date: �� / Last Updated: 08-09-2011 �:p! _ . . _ _ .�.:.