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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. Z//— d) V <br /> *ON. PO Box 66 <br /> O 0 ` Crystal Bay,MN 55323-0066 Date received: /0//1/ <br /> °" I Received by: <br /> Street Address: <br /> ; 1 . 2750 Kelley Parkway Plan review fee: <br /> �9xEsxo$" Orono,MN 55356 <br /> Total Fee: a/ 2‘ (5 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION:iv <br /> Job Site Address: rj`yS5-- (I 16+ B r)43V:k O 01 1 ilk mss-.3( <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? 0 Yes No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION• <br /> Name: Hilt - �t Expiration Date: 3/�3 j �c / <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes thatwere cQnstru ed prior to 1978 <br /> Phone: 4 "- t '-(24 7/ office) � � (�e cSZ.)(cell) <br /> Mailing Address: o f'D F$,r r k.S cyt. City: 'ir'lIN ZIP: S '5 o oZ y <br /> Contact Person: _ - t4 t4.5__ Applicant is: ontrac o / omeowner (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER I ORMATION: <br /> Name: /4 Vl f. h <br /> Phone (day): — _ V7• Cr 0 no ZIP: <br /> Address: j'S" /1 �r�� City:C.� � S s—s <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) 0 Remodel 0 Fire Damage MCIND review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> pg-Re-roof,asphalt 0 Repair 0 Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar 0 Restoration 0 Water Damage Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(specify) 0 Siding 0 Other:(specify) Fax: 952-471-0682 <br /> 0 Window(s) www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ J!� rev <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 supply the information,the application may not be issued. <br /> Applicant's Signature: Date: / j <br /> Last Updated: 08-09-2011 <br />