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f City of Orono rt Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: DDw* PO Box 66 q Crystal Bay, MN 55323-0066 Date received:Street Address: Received by: 2750 Kelley Parkway Plan review fee: Orono, MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us TI}is�applica ' n form must be completed in full and all required information must be submitted. G� Incomplete applications will be returned. (Please print) GENERAL INFCRll ON: Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No 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 required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/ APPLIC NT INFORM TION: Name: LO State License # -7 ' Expiration Date: ( 3 Lead Certification Number: n/ f-- �J-1 Expiration Date: 2 (for work on homes th t were constructed rior to 1978 Phone: Z- CJ(]� 7( (office) (cell) Mailing Address: C7,5 7 f- n1yVV-1(< +Vf City: j ZIP: /Z, Contact Person: /Vl Applicant is: Contractor / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER INFORM T!� ION: Name: 9\ C �.�(,( Phone (day): C�t�2-7-0 --7 0 S-,(, Address: yyt�e City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: IAny earth movement may require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review& permits: Minnehaha Creek Watershed District(MCWD) Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 1 ❑Window(s) c2nr www.minnehahacreek.org Overall Project Description: Estimated Construction Valuation of Project (excluding land) $ o APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete: • Some or all of the information that you are asked to provide on this cation is classified by State law as either private or confidential. Private data is inform tion which ge not be given to public but can be given to the subject of the data. Confidential data is informa ,on which rally cannot be given to el er the public or the subject of the data. Our purpose and intended use of this nfor ation is to a Ily update our ords and records of other governmental agencies required b law. If you refuse to s I the i orma on,th on may not be issued. Applicant's Signature: Date: mast Updated: 08-09-2011