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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> 'Qv 0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: G <br /> a a Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> ZS140 Orono, MN 55356 <br /> Total Fee: / At:�) !O <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 /> Inc mplete applications will be returned.�Please print) <br /> GENERAL INFORMATION: r� �IOSh4owcal <br /> �� �j�JobSite Address: �" ( 1 nj(,/ ) /C/Will this be a Parade of Homes, Remodee Home or other Display Home? ❑ Yes ANo <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/ LICANT IN OR TI <br /> Name: elluef b x et��dt�� <br /> State License # �, ���� ��~�`� Expiration Date: _w r �3 <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) v - (cell) <br /> Mailing Address: � ,� Z�'� �(� City: s ZIP <br /> Contact Person: Gr� � Applicant is: ractor) / Homeowner (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNERPFFOMATI hj; <br /> Name: <br /> Phone (day): ce1 -71 <br /> ZIP:-5-5 <br /> Address: d ��® ,r�; jrl � ' Cit � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ElDoor(s) El Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> e-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) Phone: 952-471-0590 <br /> s <br /> ( p y) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑ Window(s) www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) $ o <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 informatio which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is informatwhich generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this Worf7tion is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to sti I Ae information,t lication ma n t be issued. <br /> r� <br /> Applicant's Signature: f Date: <br /> Last Updated: 08-09-2011 C <br />