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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> windows, doors, siding, re-roof, etc. <br /> MlaN g Address: Permit number ?l10 —&0 <br /> Q,�O Box as <br /> Crystal Bay,MN 55323-0086 Date received: <br /> Street Address: Received by- <br /> 2750 <br /> y2750 Kelley Parkway Plan review fes: <br /> Orono,MN 55356 <br /> ��q•�� <br /> Main: 952-249-4600 Fax: 952-2494616 www.ci.orono.mn.us I <br /> Total Fee: <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be istin, a& (Please print) <br /> GENERAL INFORMATION: r-- <br /> Job Site Address: -'WkLL Roi o a rnd ME <br /> Will this be a Parade of Homes,Remodels howcase Home or other Display Homed Yes No <br /> N yw a spadaf avant parmk Is requred with Polfoe Depwbnent and Cfly Coundi approval W dapplor to the event. Shuft bus wiB be <br /> required trdess apptcant dairmatretes wffidant on-de padd►g is aveft*. Nw-permuted events wo not be slowed. <br /> CONTRACTOR I APCANT FORMATION: <br /> Name: <br /> State License Expiration Date: <br /> Lead Certification Number. AjAr - C1 y4?oo1- 1 Expiration Date: '90 15 <br /> (for work an/comes that were constructed prior to 1978 (Cell) <br /> Phone: ( _ (office) <br /> Mailing Address. City: ZIP: <br /> Contact Person: Applicant is. C / Homeowner tcrrca ono <br /> Email and/or Fax: Emrcn�RsnD 0 n-COM <br /> PROPERTY OWNER FORMAT L <br /> Name: I log rylnw <br /> Phone(day): t' 61 JL - City: ZIP: 5-535(� <br /> Address: /:�(yo 1Cxlb u-wd '( <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: any girth movement nay require <br /> MC1WD review&permits: <br /> ❑Door(s) a Remodel ❑Fire Damage Minnahsha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Desoaven,MN 55391 <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Phone: 952471-0590 <br /> ❑Re-roof,other(specify) ❑Skiing ❑Other.(sw*) Fax: 952-471-0682 <br /> wo w.minnehahacxeek.oro <br /> ❑Wfndow(s) <br /> Overall Project Descri on: M <br /> Estimated Construction Valuation of Project(exciudlnp land) $ 26,DDo <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all infom>ation required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of hWher knowledge. The applicant roc ognt ms that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no aftemative <br /> but to 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> fired by law. If you refuse to sqly the information,the application may not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 08.09-2011 <br />