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w ! RECEIVED <br /> � <br /> Cid o Orono nrT <br /> o� <br /> Building Permit Application for Maintenance / Reno <br /> ���®�oNo <br /> .41 <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> Permit number: <br /> PO Box 66 <br /> /Q O Crystal Bay,MN 55323-0066 Date received: <br /> Street Address: <br /> Received by: <br /> �� •� 41 2750 Kelley Parkway Plan review fee: <br /> -- <br /> 0 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: y <br /> ] <br /> Job Site Address: 1 3 - V i QL <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> tf 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/APPLICAN`�MATION:� � - <br /> Name: l(}Y' 4-c <br /> State License# Expiration Date: <br /> Lead Certification Number. Q- ,�)— I Expiration Date: LJ <br /> (for work on homes that were constructed prior to 197 <br /> Phone: /-" Z (office) (cell) <br /> Mailing Address: City: tcD ZIP: <br /> Contact Person: ApVicant is: _-Contractor / Homeowner (circle one) <br /> Email and/or Fax: , C,YN—) <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone(day): <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 ❑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 ❑ estoration El 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) <br /> www.minnehahacreek.org <br /> 1 <br /> Overall Project Description: d <br /> Estimated Construction Valuation of VfWect(excruding land) $ <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 SUPRVthe information,the application may not be issued. <br /> Applicant's Signature: „ Date: lUx <br /> Last Updated: 08-09-2011 <br />