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City of Orono �T 786 . 7-� <br /> Building Permit Application for Maintenance / Renovation <br /> - (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <�)D/3 <br /> �., PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a t Street Address: Received by: <br /> �� o~ 2750 Kelley Parkway Plan review fee: /3-O e>aI3 <br /> �9kESHot'� Orono, MN 55356 tri 111 <br /> Total Fee: <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 /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: iqp55 7,o_yb V CW Zq riG <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: Q/70X ,I7-i ?/ /IC_. <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date.- <br /> (for <br /> ate:(for work on homes that were constructed prior to 1978 <br /> Phone: - -4-3,6,0 (office) to 17--Zo - Z 987 (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: CfA Applicant is: Contracto / Homeowner (Circle One) <br /> Email and/or Fax: �?/CSG �(e/ axGD '!') 95? 7V&- #383 <br /> PROPERTY OWNER�I'N"F"ORMATION: <br /> Name: �h9r�D 4 IRQtl�c /Gl[✓5/• <br /> Phone (day): <br /> Address: w City: r or)O zip: 553 <br /> Email and/or Fax r'Q��, ��•C! . ��m <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 /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑Siding ❑Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Overall Project Description: Q /7 j-�r' - a'k"4AZ / &Ve etvm o 0 A0 <br /> Estimated Construction Valuation of Project(excluding land) $ /00i coo <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 informhinnorrmation <br /> which generally cannot be given to either the public or the subject of the data. Our l <br /> purpose and intended use of this is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refu sthe information,the application may not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 08-09-2011 <br />