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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: 0 f s b <br /> !,, PO Box 66 <br /> 0 Crystal Bay, MN 55323-0066 Date receive : 2.--- <br /> a <br /> J <br /> Street Address: Received by: <br /> LI ' <br /> 2750 Kelley Parkway <br /> Orono, MN 55356 Plan review,fiee <br /> Total'Fee: 4,87, <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: -oed� I �4S <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes r 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: ,,-.04/7(6 .44f <br /> State License# ; _ Expiration Date: '—3 <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: -74' >- � so <br /> (o ic ) (cell) <br /> Mailing Address: - . ( "l - a� (/Asid�( Citi / A 0 ZIP: S�_GJ <br /> Contact Person: /40(1,.\ / <br /> Applicant is: CC_o_ntractor / Homeowner (Circle One) <br /> Email and/or Fax: __.._.......__. <br /> PROPERTY OWNER INFORMATION: A . / ) i, q/ <br /> Name: ___ <br /> (/( <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> CIDoor(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> : Re-roof, asphalt Minnehaha Creek Watershed District(MCWD) <br /> ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ e-roof, cedar <br /> El Restoration CI Water Damage Deephaven, MN 55391 <br /> CIRe roof, other(specify) Phone: 952-471-0590 <br /> ( p y) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> CI Window(s) www.minnehahacreek.orq <br /> Overall Project Description: t� <br /> Estimated Construction Valuation of Project (excluding land) $ gj J �:(X <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 aseither 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 kbis information is to annually update our records and records of other governmental agencies <br /> required by law. If you refusi 'to'supply the information,the application may not be issued. <br /> Applicant's Signature: 'lb: �.- -- <br /> Date: <br /> Last Updated: 08-09-2011 <br />