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City of Orono <br /> Building Permit Application for Maintenance 1 Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> �---�. Mailing address <br /> Permit number: <br /> O, PO Box ss 0 �Oql <br /> Crystal Bay, MN 55323-0066 Date received: 8 t <br /> Street Address: Received by: <br /> �+ 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> Main: 952-24SA600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: <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: 0P -7o-#1 4/,* -Ad, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 'Yes o <br /> If yes,a special event permit is required with Police Department and City Council approval BO days prior to the event Shuftie bus icewill be <br /> required unless applicant demonstrates sut8clent on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: j.._ <br /> State License# _ �r 2Z Expiration Date: <br /> Lead Certification Number: <br /> Expiration Date: <br /> (for work on homes that were constructedr* to 1978 <br /> Phone: l - (office) (cell) <br /> Mailing Address: L/ Gi ZIP: <br /> Contact Person: ,� t , Applicant is: Contractor 0 Homeowner (circie one) <br /> Email and/or Fax: - S71 ^o <br /> PROPERTY OWNER INFORMATION: <br /> Name: .44� ,� �' ,- <br /> Phone(day): , ' <br /> Address: fairy, City: ZIP: <br /> Email and/or fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits: <br /> ❑Do r(s) ❑Remodel El Fire Damage p <br /> Minnehaha Creek Watershed District(MCWD) <br /> e olof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 9521171-0590 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other. (spedfy) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Overall Project Description: <br /> Fe- <br /> Estimated Construction Valuat on of Project(excluding land) $ Lj&& <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: OS-09-2011 <br />