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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> A, Mailing Address: Permit number: a 0 (1p` l- <br /> �Of y PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> �tkll Street Address: � Received by: <br /> Z� v 2750 Kelley Parkway Plan review <br /> Orono, MN 55356 /� pp <br /> Total Fee: <br /> �qk�s H��'� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us I t cz� <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: 37/c> <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �M No <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: 60yep— QUArUbrNG CTP, <br /> State License# SCC go 2980 Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) Plq-Z-•-71e7- 787.3 (office) 9 fl- 2 oq 7 <br /> Mailing Address: ?Y3 S C+ R4 (o( City: VV"T r_PC ZIP: S3gg <br /> Contact Person: '3e*- Fr o.n so rti Applicant is: ontracto / Homeowner (circle one) <br /> Email and/or Fax: •�e� • �r o.tiso� bo�.,� bv,+►td,Rg . C o.r� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ,S1�a r-.r..v` tt, �ec-k•� I�ew.o_a__ <br /> Phone (day): -763 - ?q(-- <br /> Address: <br /> 4t.-Address: 3 3 it w ol�e. P-d City: Qrono 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) lK 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.org <br /> Estimated Construction Valuation of Project(excluding land) $_ _ 1300000 <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 data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the inform . n,the application may not be issued. <br /> Applicant's Signature: -` Date: 4 - 13 -/6 <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />