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City of Orono <br /> Building Permit Application for Maintenance/ Replacement/ Remodel —Vesiidential ONLY <br /> (i.e.windows,doors, siding, re-roof, etc.-NO STRUCTURAL EXPANSION) <br /> MarrPermit number: _d <br /> PC Box <br /> 0 Crystal Bay,MN 55323-0066 Date received: 9 '� <br /> Street Address: 6 Received by: <br /> 1 y 2750 Kelley Parkway Plan review fee: <br /> Orono,MN 55356 zz <br /> t'KFS H 04� Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 wwyv.ci.orcno.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 /> .lob Site Address: -37-11S- a O <br /> WIN this be a Parade of Homes, Remodelers Showcade Home or other Display Home? 0 Yes No <br /> IF yes,a special event permit Js required with Police Department and City couna7 approval 60 days prrorto the event. Shuttle bus service wit be <br /> required unless applkent demonstrates sufficient on-site parking is available. Non permitted everts wiR not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: l <br /> Name: Qtly.eC� egc `1/cJl rr011 L __ <br /> State License## C,���2- Expiration Date. - 3(— <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 9978 <br /> Phone: (cell) ').^ (office) <br /> Mailing Add n�s: � �•`r City: J G� � ZIP: S 31 <br /> Contact Person: �ficantJs: ontractor / Homeowner Icimisom) <br /> Email and/or Fax: 4V�E <br /> g, c l � G Al L <br /> PROPERTY OWNER INFORMATION.- <br /> Name: <br /> NFORMATION:Name: e 10 6 t r <br /> Phone(day): 91 h -- ` cr 7- /D 'S� Ctiy ZIP: <br /> Address: `7 i o o iE F� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall prglect descri on: Any earth movement may also require <br /> Type of Project: MCWD review&permits: <br /> ❑Door(s) ❑Remodel ❑Fire Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> '%te-roof,asphaR ❑Repair ❑�rm Damage 15320 Minnetonka Blvd <br /> /❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> ( '? <br /> (I <br /> ❑Re-roof,other(specify) ❑Siding Other: Fax: 952-471-0682 <br /> ❑Window(s) www minnehahacreek.ora <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 /> u refuse to su I the inform tion,the a ication may not be issued. <br /> Date: � / <br /> �^! 7 <br /> Applicant's Signature: <br /> r. <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br /> L'd d97,:Z0'LL£L deS <br />