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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O�O Mailing Address: Permit number: 20! 5 ' U I a I <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: y' �CjJJ <br /> Street Address: - ._Received by: '(�Si) 1 �`P <br /> tiF 2750 Kelley Parkwa (Cj b 2�2 Plan review fee: 2.31 - 51 Id L 'L-" <br /> Orono, MN 55356 <br /> titESHOV- _.. <br /> Total Fee: q 7 , 0, <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.(rrkS9 JO/9ks: <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: r� �� 8 I �d 'j^ / <br /> Job Site Address: d,�° 14) Via r� V V V <br /> Will this be a Parade of Homes, Remodelers Showca a Home or other Display Home? ❑ Yes <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 /> a di Name: es <br /> r E ti cicso- <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (0/Z p 2,37I (office) 7� q2 -3 3 €199 <br /> Mailing Address: 41,&._ �Obn/ I City: Z. 4, ZIP: _) _.5-5-35--C <br /> Contact Person: j 7 - Applicant is: n rac 1! Homeowner (circle one) <br /> Email and/or Fax: Q.ri ckson b rel_' 4 al'/ - 0-7-1 <br /> PROPERTY OWNER INFORMATION: / <br /> Name: �j r& S�, r=' <br /> d >1r C h c f rere_/-Sc,'1 <br /> Phone(day): r/, Vq0 '43 7 / 144 <br /> t <br /> Address: .(o &v6- /,h f/4 City: 0-71/ 14 ZIP: /i/� c_57576Email and/or Fax: ,e r'r Sar��!'c..of y , r �,_)„�, <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ElDoor(s) ►remodel 0 Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt 0 Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar 0 Restoration mater Damage Minnetonka, MN 55345 <br /> El Re-roof, other(specify) CISiding the : (specify) Phone: 952-471-0590 <br /> 0L 0 Fax: 952-471-0682 <br /> 0 Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ QROje-. <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 informati• ,;,,;,�i_alto'may not be issued. <br /> Applicant's Signature: `.�% .,�� Date: d' �S <br /> OFOOPher45, <br /> Owner's Signature: - _ Date: ' <br /> Last Updated:January 2015 <br />