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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 /> O�,01►�,0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> �' <br /> NStreet Address: Received by: <br /> Gti`4 2750 Kelley Parkway Plan review fee: <br /> 9kES140 Orono, MN 55356 <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: � 7 3 "� // <br /> %i7 1< << <;, c/Y <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: <br /> State License # 2 ©d 3Lp7t 5 y Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: �'s y 5�/3 _ J'6 6.Z (office) 6 J'Z 3'!0 c 7Y1 (cell) <br /> Mailing Address: Cit ZIP: <br /> o V _-, 'T-3 b <br /> Contact Person: Sz >rtiApplicant is: tracto / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: � v i'el ���� f j <br /> Phone (day): -S Z 2. 17 3 31-'S <br /> Address: y73 City: re-,V7"-) zip: <br /> .�3 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Dgef(s) El Remodel E] Fire Damage <br /> MCWD review &permits: <br /> L^✓1./RMinnehaha 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 /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehah2creek.org <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ /Q 0 p 0, C­ <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 information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the information, the application may not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 08-09-2011 <br />