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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 /> "8 .0.A/ <br /> r A Mailing Address:PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> F G Orono, MN 55356 <br /> `"IkESH0°' Total Fee: <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: <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase 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 service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. /� <br /> CONTRACTOR/AP LIC,� NT INFORMATION: r`e& <br /> Name: APPLICANT <br /> tI W1 i,-( <br /> State License# 8 C (0 3 310 3 Expiration Date: dI fi-n.e' 20 5 <br /> Lead Certification Number: {L-r3voc ^I o -DCo 13 (l ZOS) Expiration Date: pfGB W 15- <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (19-2, 6„.5ry Z8ez2 (office) <br /> Mailing Address: ) Zalir 13E fi`` _, City: k i out ZIP: S-3 , <br /> Contact Person: =f (Y\ (DSL Applicant i : ontractor / Homeowner (Circle One) <br /> Email and/or Fax: COytf -,.1c e., Avg, . cd,), <br /> PROPERTY OWNER INFORMATION: <br /> Name: 4.i-- . __ <br /> Phone (day): q 5-2. 472. (008" <br /> Address: 41225 g ,c,H- 12 at() City: ZIP: 55 3(,/. <br /> Email and/or Fax: <br /> • <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ElDoor(s) %Remodel CIFire Damage MCWD review& permits: <br /> 11] Re-roof, asphalt 111 Repair 111 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) CISiding [' Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) . $ 1(4)( . <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 i • ,, the appli ..• ay not b- .ssued. tt <br /> Applicant's Signature: ` , � Date: I\16)V 249 9 <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />