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1 <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc )�e,.� <br /> �0� Mailing Address: Permit number: C —yV <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 7 <br /> Street Address: Received by: <br /> y� 2750 Kelley Parkway Plan review fee: <br /> L Orono, MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: 5 <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 INFORMATIO <br /> Job Site Address: 176 Lmiv% ` H (� ��,` P<3r <br /> Will this be a Parade of omen, emodelers Showcase Home oth r DisplayHome? ❑ Yes -AVO <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: A)ne c---' <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that►►yyere constructed prior to 1978 <br /> Phone: (cell) Ll g8 ZZ S g oil (office) <br /> Mailing Address: L; City: �p{� <br /> Contact Person: Applicant is: Contractor / om wner (Circle One) <br /> Email and/or Fax: dry 2'- <br /> PROPERTY OWNER INFORMATION- <br /> Name: <br /> NFORMATION- <br /> Name: ��4 A <br /> Phone(day): 9 86 27-5 e 15 y <br /> Address: P80 City:In", ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ CA el. — <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 are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> 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 daVisinfmation which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is infohich gene ally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this infoann yupdate our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the n,th li on may not be issued. <br /> Applicant's Signature: Date: z/! <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />