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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 /> ".!L*1\111L <br /> O A Mailing Address: Permit number: <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a <br /> Street Address: Received by: <br /> GSC2750 Kelley Parkway Plan review fee: <br /> kESHo�`` Orono, MN 55356 /i /_"7 32 <br /> Total Fee: /`7 <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: ,p <br /> Job Site Address: .;.< ( to Gki, La j. t - e f`- c <br /> Will this be a Parade of Homes, Remodelers howcase Home or other Display Home? ❑ Yes XI 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 INFO MATION:n <br /> Name: /14c6CuXxi1 .6e.;,5,,,, >'lJii,' _- -,tic <br /> State License# Arc(, 4,2 6 :Q 2 Expiration Date: 3. 3/-/S- <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 / <br /> Phone: (cell) 73---2-,2/2 /f6( (office) (S'cr <br /> Mailing Address: ///go 33tW „sr,, / City: s-y-,ii9/e1ao/ ZIP: - <br /> Contact Person: -1a.1 irlr. C;- ur rn Applicant is: Gro ltracter-' / Homeowner (Circle One) <br /> Email and/or Fax: jokn c� 7/1c c,4)•4,e7,7 D e j-9,, Bak/ ,C C,"t <br /> PROPERTY OWNER INFORMATION: <br /> Name: Clnd/'� 1y 0cli z <br /> Phone (day): 6/2_ 3S'.2- 3 7 VC <br /> Address: 2 (/0 LrJ, Z.eet7...g Re ecer' City: e R 0 ZIP: 3-$-3 3/ <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: ///S)1m// e,ZtesS wpv....p �- fir'/( <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) E Remodel ❑ 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) ❑ Siding 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> $Window(s) VA'S'S www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ 4.6 00 <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 govemmental agencies required by law. If <br /> you refuse to supply the information, <br /> ,tthe application may not be issued. <br /> Applicant's Signature:-- /i''/ -- -- Date: // 2-O --/ <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />