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1� <br /> n l�' <br /> �d 5 <br /> to <br /> City of Orono <br /> Building Permit Application for Maintenance 1 Replacement/ Renovation <br /> (No structural expansion. Only windows,doors, siding, re-roof,etc.) <br /> 0.... Me/i/ng Address: Permit number:. (3 <br /> e. PO Box 66 <br /> Crystal Bay,MN 55323.0066 Date received: �- <br /> 1 Street Address: RooNved by: <br /> y 2750 Kelley Parkway Pain review tae: <br /> �r4Ktstloer`c Orono,MN 55356 <br /> total Fee: <br /> Main. 952-249-4600 Fax: 952-249-4616 www.cl.orono.mmus <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: 3-7 y_,> -To e>0 &20JJob Site Address: <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home?—II Yes El No <br /> a yes,a speciol event pem l is regtared with Police Department and Cay Council approva180 days prior to the event. Shuffle bus service will be <br /> requrred unless epphrent demonstrates aLdiicrent on-ske parkbtg is aveideble. Mon-parmaw every wel not be afowed <br /> CONTRACTOR 1 APPLICANT INFORMATION: / <br /> Name: _ , 4 V Y c yy1 GN'N le <br /> State License# 9C. .19 i y 1%3 Expiration ate: � <br /> Lead Certification Number: 'ymr- 1 i40t 5-I Expiration Date: 11--44_1le <br /> (for work on homes that were constructed prior to 1918 <br /> Phone: <br /> Mailing Address: I%-uC> F,-%H ( ,„1~ City: rry „Cy. 21P: <br /> Contact Person: ` IS/�Nr7�3i. Applicant is: I Homeowner forewon.) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATIO . <br /> Name: J,// -0 <br /> Phone(day): /.12-�l 3�t`o It ,� // <br /> Address: :Zt- �1r�Lo.,woc.c>/ ��� City:Aff"L4L IP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: N <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) 12 Remodel ❑Fire Damage MCWD review&permits: <br /> j ❑Re-roof,asphalt ❑Repair ❑Storm Damage Mlnnehahe 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 /> ElWlndow(s) www.minnehaMarak,oro <br /> Estimated Construction Valuation of Project(excluding land) $ ,.oec) <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 hislher knowledge. The applicant recognizes that they are <br /> i solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no akemative 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 to 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 t annually update our records and records of otter governments]agencies required by law. If <br /> ,___you refuse to su I the I plication may not be Issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: > Date: I[17 _ <br /> Last Updated 0 310 612 01 3 <br />