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City of Orono <br /> ` Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> O �O Cr Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> 0Orono, MN 55356 I' <br /> �'kESH4` <br /> Total Fee: IxljJ <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us )5 <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: <br /> Will this be a Parade of Homes, Remodel rs Showcase Home or other Display Home? ❑ Yes 5J 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 service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INF RM TION: <br /> Name: .till- l` <br /> State License # Expiration Date: <br /> Le-d Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) (cell) <br /> Mailing Address: ; City: %,L;, ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �? c,ut•1�.i oar• o "h <br /> PROPERTY OWNER INFORMATIOT4 <br /> IName: �l r'S S e <br /> Phone (day): 74, PS— Cs,ScJy <br /> Address: 3GFE n_.!5,c City: ✓0 1 ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review &permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> A�tWindow(s) www.minnehahacreek.org <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) $ tl <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> I <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <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 th' information is to annually update our records and records of other governmental agencies <br /> required by law. If ou refuse upp[V the information,the application may not be issued. <br /> Applicant's Signature: ZZ- Date: <br /> Last Updated: 08-09-2011 I/ <br />