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i .� � Cit of Orono ��2� y .� F uilding Permit Application for Maintenance / Renovation �'� � �� :. (windows, doors, siding, re-roof, etc.) � �; � . Mailing Address: Permit number. �� j� ' ("�I L`/� Z. ��,� � PO Box 66 3. � Crystal Bay, MN 55323-0066 Date received: �� L' '� �� ,� ;; �, Streef Address: Received by: `, ;� �.�,t �t -�` Gti 2750 Kelley Parkway Plan review fee: ,; `�kEsxo4`'� Orono, MN 55356 > ' Total Fee: 4t 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 I FORMATION: Job Site Ad ress ��(��U �� X �'c� Will this be Parade of Homes, Remodelers Showcase Fiome or other Display Home? ❑ Yes �-Fd'o �,. If yes, a sp ciaf event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be equired unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �`e CONTRACT R/APPLICANT INFORMATION: � :�� Name: L � � ��iri., v i o�� State Licens # e��f��I�/ Expiration Date: 3 � Lead Certific tion Number: Expiration Date: �; (for work homes that were constructed prior fo 1978 ;; Phone: (office) (cell) s° _ Mailing Addr ss:�� ,,��,�L S f- City: ��w ��ZIP: c�� Contact Pers n: —' Applicant is: Con r ctor / Homeowner (Circle One) Email and/or ax: PROPERTY WNER INFORMATION: , . Name: _��4�(%S , i. v�S Phone (day): Address: �3� �� n/ City•.��J� ZIP: �5`�S� Email and/or ax PROJECT I FORMATION: Type of Proje t: Any earth movement may require �,� � _ ❑ Door(s) ❑ Remodel MCWD review&permits: `�� ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) �;; [�Re-roof, as halt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ��'' ❑ Re-roof, ce ar ❑ Restoration ❑Water Damage Deephaven, MN 55391 � Phone: 952-471-0590 r �< ❑ Re-roof, ot r(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �' ❑Window(s) www.minnehahacreek.orq d� � ' Overall Proje t Description: ., Estimated C nstruction Valuation of Project(excluding land) $ �j� , =k �::; APPLICANT ACKNOWLEDGEMENT: `�' • Agrees to provide all information required or requested by the Building Department; • Certifie that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they �; � are sol I res onsible for submittin a com lete a lication bein aware that u on failure to do so, the staff has no alternative '�: Y P 9 P PP� 9 P but to r ject it until it is complete; • Some r all of the information that you are asked to provide on this application is classified by State law as either private or confide tial. Private data is information which generally cannot be given to the public but can be given to the subject of the data. onfidential data is information which generally cannot be given to either the public or the subject of the data. Our purpos and intended use of this information is to annually update our records and records of other governmental agencies ': re uire b law. If ou refuse to su I the information,the a lication ma not be issued. f'� � +_. C � Applicant's Sig ature: / ,QJ Date: ��j 9'�j Last Updated: 08- 9-2011 T� �