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Caue� <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> PO Box 66 <br /> �O Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: >/f/ <br /> 2750 Kelley Parkway Plan review fee: <br /> \t9kESH�4� / Orono, MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: 9(07. S <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: , D -1 D `-fes <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 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 INFORMATION: <br /> Name: <br /> State License # f C Z 7 2 �7� Expiration Date: <br /> Lead Certification Number: A/617: i 144 U73 —1 Expiration Date: z <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: q6�)_ N74_7t U (office) <br /> - /? _ 270- /a('�2 (cell) <br /> Mailing Address: ''� �) � �f�j/ — � Cit ZIP: <br /> City- _ . l�e✓ <br /> Contact Person.- Applicant, cans: ontractor Homeowner <br /> PPlit i �C (CirdeOne) <br /> Email and/or Fax: 0,,40C;NZp (, LISA", <br /> PROPERTY OWNER INFORMATION: <br /> Name: _ r L4,kJ 04 <br /> Phone (day): <br /> Address: 7S716 '-M • O r1City: 0600 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 /> El Re-roof, other(specify) Phone: 952-471-0590 <br /> ( p y) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Overall Project Description: ' <br /> Estimated Construction Valuation of Project(excluding land) $ Ce. <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 <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 this information is to annually update our records and records of other governmental agencies <br /> re uired hy law. If you refuse to supply the information,the a lication may not be issued. <br /> Applicant's Signature: Date: t l Z J <br /> Last Updated: 08-09-2011 <br />