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City of Orono <br /> Building Permit Application for Maintenance / Replacement/ Remodel - Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> Mailing Address.-,,, Permit number: `J ' <br /> PO Box 66 <br /> Crystal Bay, MN 55323-006 Date received: _2--C<-7 <br /> Street Address: n Received by: <br /> S� G� 2750 Kelley Parkwayli Plan review fee: x 1 <br /> .m <br /> kfSH0 Orono, MN 55356 <br /> /l <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.oronon.us Total Fee: / gV1 23 <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) <br /> Job Site Address: , To IfIK C)I-r>r\o M".? <br /> Will this be a Parade of Homes, Remodelers Showca a 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: FUert6LS Q.r- r i to S <br /> State License# o Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (c 103 -$L-$ -0 T 48 (office) <br /> Mailing Address: 1(i 0 4 f\)V-tK SKOrc bV,i City:(.dhU ZIP: S-3 io q <br /> Contact Person: � ly\ Cte_;,,-y Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: W\ C P XJ 411-1,4"tn r.-F e V- s�S o C-C r,r\ <br /> P <br /> PROPERTY OWNER INFORMATION: <br /> Name: _F V-eP:�i <br /> Phone (day): to 1a- <br /> Address: Ili Dt-t-f­ SKo,^e City: r to C ZIP: S S 36(f <br /> Email and/or Fax: i Qv e,.^6-,-T-ev\:I-,e (�•�i sc'S. c o✓r. <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑Siding Other: (specify) Phone: <br /> 952 -471-0820 <br /> ElWindow(s) a5`M� �Grn �htS�` www.min nehahacreek.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 application may not be issued. <br /> Applicant's Signature: C Date: <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />