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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: - Q d <br /> 0, PO Box 66 57 <br /> 06 Crystal Bay, MN 55323-0066 Date received: -7 <br /> 9 O <br /> a Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> �silo 4'�v Orono, MN 55356 <br /> : ��Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: <br /> Incomplete applications will be returned. (Please print) <br /> ,,t <br /> Job Site Address: 1 �Pj( Ilu Vll vl R f <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> /f 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/APPL4 CANT INFORMATION: <br /> Name: AJ W05 f V W <br /> State License# S(p 10ti}- , Expiration Date: 3 <br /> Lead Certification Number: f'N-r30_�015-I Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) cq6 (cell) <br /> Mailing Address: 05'1 4ytcirl? Cfi, City: y1-) Je ()rD✓e ZIP: <br /> Contact Person: mG 4-f-krm I Applicant is: / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATONt• <br /> Name: 20l bQ�q <br /> Phone (day): <br /> Address: 7 q�o L"-01n 261W-7 Qp � City:042wk � r� 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 /> to RU-100f, d P ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> s eci Phone: 952-471-0590 <br /> Re-roof, other <br /> (specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> _7 ?gel ❑Window(s) www.minnehahacreek.org <br /> Overall Project Description: / / <br /> Estimated Construction Valuation of Project (excluding 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 su I the information,the pplication may not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 08-09-2011 <br />