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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 /> �O1 V Mailing Address: Permit number: <JO/3 - D/2 S--O <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 4) Date received: /2 -/O- /5 <br /> Street Address: �O Received by: 46 <br /> yt<,` 2750 Kelley Parkway "t- Plan review fee: 57. 53 <br /> L Orono, MN 55356 <br /> "IkES H o4`" Total Fee: (370 13 /27q <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. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: ) /OL9 ,�� <br /> Job Site Address: -d O (Jc ?�Jc. ✓.�7(-1r <br /> Will this be a Parade of Homes, Remodelers Shbwcase Home or other Display Home? ❑ Yes ,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 s rvice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICAN FORMATION: - <br /> Name: f c,� '/r L/CScr?'-) <br /> State License# V 3 2-2, (E „ /' - Expiration Date: /26 20 • <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that w re constructed prior to 1978 / <br /> Phone: (cell) /2. y o 3 J (office) 76 3 LI73 2 7// <br /> Q 9 <br /> Mailing Address: a , ;do ._ _ ®rm• i/ City: e /„ _ ZIP: 5 S3 , <br /> Contact Person: racQ E Applicant is: Contractor Homeowne circie One) <br /> Email and/or Fax: 76 3 c(73 O `t ( <br /> PROPERTY OWNER INF RMATION: <br /> Name: 110br& ce EcrY) <br /> Phone (day): 6/2_ of 9c 233 ) <br /> Address: _ 2-i-(8(0 :66/(4 - / c/ City: /I yr c_ ZIP: S-3-3 S 6 <br /> Email and/or Fax: 763 N 73 0'46 <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) emodel El 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) IDSiding 1=1Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ '3OOO <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 information, the a••['cation ma not be issued. // <br /> 0/(J <br /> Applicant's Signature: �� f� Date: /Z(// <br /> Owner's Signature: / % Date: lZ` ���/ / j <br /> Last Updated: 03/06/2013 <br />