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� "�?�' ,��x �:;3°�". �a � � City of Orono � 4 ` � � � �; Building Permit Application for Maintenance / Renovation ' ,~ �:� �� (windows, doors, siding, re-roof, etc.) � Mailing Address: � �,� PO Box 66 Permit number: �� --� � � �: �'' 0 O Crystal Bay, MN 55323-0066 Date received: � , � �w ��-� Received by: ,: � I� �.�._ �, Street Address: �N . ��t t �„�p„ �ti 2750 Kelley Parkway Plan review fee: '� 9 {�� Orono, MN 55356 �, � Esxo; _ , ...: �, __ � _ Total Fee: � / '� #✓ Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �� '-� l� �' a'� ' This application form must be completed in full and all required information must be submitted. �� Incomplete applications will be returned. (Please print) � GENE AL INFORMATION: xd �� Job Si e Address: � ��1 S V�X �� Will th s be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No �� If ye , a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus servic�will be � Y, required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONT ACTOR/APPLICANT INFORMATION: `� � Name: �f k �r.s ]..o�e C o r�S�- k State icense# Ex ir � ��2 ��; 373 p� ation Date: -"31- 13 `_ Lead ertification Number: Expiration Date: � (for ork on homes that were construcfed prior to 1978 ,�� ' ' Phone '�7 6"3-232, Z�3 I (office) ��lo �,- SS�3�l 3 (cell) '� �` Mailin Address: �SZ3 P�� S i r�� City: ZIP: � ° Conta t Person: Applicant is: Contractor / Homeowner (Circle One) � Email nd/or Fax: �, �t � fi� ` ' PROP RTY OWNER INF MATION: Name: �� � ;� ,�� Phone (day): �� �x' Addre s: City: ZIP: �:.. Email nd/or Fax ,� � ,,> PROJ CT INFORMATION: <�� � Type o Project: Any earth movement may require �� ❑ Doo (s) ❑ Remodel ❑ Fire Damage MCWD review&permits: � �. Minnehaha Creek Watershed District(MCWD) p '' �Re- of, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ,� ,�'. �,' ❑ Re- of, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ;:� � ❑ Re- of, other s eci Phone: 952-471-0590 '� ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �P �� ❑Window(s) www.minnehahacreek.orq `� 1,F ��' Overa I Project Description: `�eu� G-f--�- h c �u�s` �- Gh�-< -�- ��. j�, ,� � � _�� Estim ted Construction Valuation of Project(excluding land) $ � d�� . ` � �� APPLICANT ACKNOWLEDGEMENT: M � • Agrees to provide all information required or requested by the Building Department; �� ",i �� • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they ��. �Y:! are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative 4" 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 ;�:F 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 r� 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 refuse to su I the information, the a lication ma not be issued. �u; � ��-3 - i� f` Applic nYs Signature: �I� 2 Date: �, ,� Last Upd ted: 08-09-2011 ;y . ._ �_ ._ .�. .. .,. _ ._�