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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O1 V Mailing Address: Permit number: <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> yF G� 2750 Kelley Parkway Plan review fee: <br /> t 0SHO �, Orono, MN 55356 � <br /> � <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <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? es ff 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 INFO M <br /> Name: —rL��4, /,/ �ATION/;(! G�2 t��WJ -L, <br /> State License# a Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 ff c/ F <br /> Phone: (cell) ;L _ (office) �J` <br /> Mailing Address: �y 7 City:p c ZIP. <br /> Contact Person: J , ' Z; Applicant is: Contractor / Homeowne (circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> R <br /> Name: <br /> Phone (day): q'T., ffTV If 6�// 4f9 , <br /> Address: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ R model 1-1 Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt pair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project (excluding land) $ , <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department, <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> 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 data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the information,the applicatiop may not be issued. <br /> Applicant's Signature: lh Date: <br /> C - ��/ <br /> Owner's Signature: -� Date. <br /> Last Updated: 03/06/2013 �/ <br />