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1 L <br /> City of Orono <br /> Building Permit Application for Maintenance I Renovation <br /> (windows, doom, siding, re-roof, etc.) <br /> Mailing Address: <br /> � PO Box 66 <br /> Permit number: O` b 16 , <br /> �., \ <br /> Crystal Bay, MN 55323-0066 Data received: <br /> I�a� I Street Address: Received by: <br /> o 2750 Kelley Parkway Plan review feet <br /> Orono,MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: �1 <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: <br /> Incomplete applications will be returned. (Please print) <br /> / <br /> Job Site Address: �V/909 /V <br /> Will this be a Parade of Homes, Remodelem Showcase Home or other 1511splay Home? Yes No <br /> !f 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 avallable. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: / <br /> Lead Certification Number: ..- 1 Expiration Date: <br /> (for work on homes f f f were nsi?ructed prior to 1978 <br /> Phone: � (office) t25��x �7^ S;rq- Kz L/ (cell) <br /> Mailing Address: j Citic: -- ZIP: <br /> Contact Person: / Applicant is: Contractor Homeowner (cirdeone) <br /> Email and/or Fax: "—�"- <br /> PROPERTY OWNER INFO M-4 N: <br /> Name: <br /> Phone(day): _Z <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door s) ❑ Remodel [I Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> e-roof,asphalt [I Repair El Storm Damage 18202 Minnetonka Blvd <br /> [3 Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 <br /> E]Re-roof,other(specify) [I Siding Phone: 952-471-05900 <br /> g ❑Other. (specify) -0682Fax: 952-471682 <br /> ❑Window(s) www.minnehahacreek orq <br /> Overall Project Description: — 0 !!e -- <br /> Estimated Construction Valuation of Project(excluding land) $ 0 <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_, ate our records and records of other governmental agencies <br /> required b law. if you refus cinsatign tha onnkmion may not be issued. <br /> Applicant's Signature: r _ <br /> Last updated: 08-09-2011 <br />