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�ftn. 30. 2018 . 11 :400 No. 4351 P. 1 . City of Orono Building Permit Application for Maintenance/Replacement/Remodel— tes . r>IQ'�VLx (i.e. windows, doors, siding, re-roof, etc. —'NO STRUCTURAL EXPANSION Q A, Mailing Address: {V PO Box 66 Crystal Bay, MN 55323-0066 'Ikca vetl -- -r4;A LL„:�` at _ 0 .� Street Address: fecelved �� 2750 Kelleypartcwa = = yakO�� Orono,MN 55358 ESH Main: 952-249-4600 Fax 952-249-4616 cl.oron us This application form must be completed In full and 211 required Information must be submitted. GENERAL INFORMATIO Incomplete applications will be returned. (Please print) � Job Site Address; '2- Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o Nyes,a special event permit rs required with Police Department and City Council approval 60 days prior to the event. Shuttle bus sa6ioa NY be required unless applicant demonstrates sufficient onsite parking is available. Non permitted events will not be allowed. CONTRACTOR/APPL CANT INFORMATION: Name: v' State License# Expiration Date: Lead Certification Number: C7 r Expiration Date: (for work on homes that were constructed prior to f 78 Phone: (cell) (office) Mailing Address: t� City: ZIP. Contact Person: �. Applica t is; on / Homeowner (Circle ones Email and/or Fox; .f C C PROPERTY OWNER INFORMATION: Name: � khylqs Phone(day): Address: 4 �. �� Vy� City: f( ZIP: Email and/or Fax; PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review$permits: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) ❑Re-roof,cedar ❑Restoration15320 Minnetonka Blvd ❑Wafer Damage Minnetonka,MN 55345 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 indow(s) Fax 952-471-0682 m8my.minnehahacregKom Estimated Construction Valuation of Project(excluding(and) $ APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department, • Certifies that the information supplled 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 application is classified by Slate law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of thifinfa on is tb update our records and records of other g vemme tal agencies required by law. If ou refuse to su Io attarcation ma not be issued. �( Applicant's Signature: Date: V Owner's Signature: Date: Last Updated:January 2016