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City of Orono <br /> Building Permit Application for Maintenance / Renovation`,,' <br /> (windows, doors, siding, re-roof, etc.) `�' <br /> Mailing Address: 0��l a <br /> 0 PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: j- Z <br /> a s Street Address: Received by: / <br /> 2750 Kelley Parkway Plan review fee: /✓- <br /> r9kZSIH04� 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: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other 15isplay Home? ❑ Yes �' o <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/APP [CANT INFORMATION: / <br /> Name: RV e, Y2"4� �VC+Pc/;fC <br /> State License # .;L0 >> y Expiration Date: 3Z,' _3 <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: ( fZ Cvl� _i y2 (office) (cell) <br /> Mailing Address: 50 F�.� /'-,b City: �,' %<J�'� ZIP: <br /> Contact Person: ��,� v Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: ! ioCCA ':1112a I <br /> PROPERTY OWNER INFORMATION: <br /> Name: �� �;ff,574�, <C-, <br /> Phone(day): t Z— (-,7 C) �(ZZ <br /> Address: 5 '� e4 b3 e <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: <br /> ❑ Door(s) ❑ RemodelFir <br /> ❑ <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Stc " <br /> ❑ Re-roof, cedar ❑ Restoration ❑Wa <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Oth A " '� <br /> � El Window(s) <br /> V�p <br /> Overall Project Description: `!)GCV (0�, ex e �l� 4 <br /> Estimated Construction Valuation of Pr � ' "",� <br /> o�ect(exc d Yyf �Y)i <br /> APPLICANT ACKNOWLEDGEMENT: v' <br /> • Agrees to provide all information required or requester lu <br /> • Certifies that the information supplied is true and corn <br /> are solely responsible for submitting a complete appiic <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to p <br /> confidential. Private data is information which general <br /> data. Confidential data is information which generally _ ., J�� L of the data. Our <br /> purpose and intended use of this i_nfprrT1ation is to ann dno records of other governmental agencies <br /> required by law. If you refuse t u the information,tiie application may not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 08-09-2011 j l Z <br />