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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> �o V Mailing Address: Permit number: c c?O/4 -I'D /7 5- <br /> O PO Box 66 ^� <br /> Crystal Bay, MN 55323-0066 Date received: Cr !17-1 (p <br /> Street Address: Received by: �� �" <br /> a _ <br /> tiF L 2750 Kelley Parkway Plan review fee: 1 if r `),�-ic « , <br /> `�kESHOR� Orono, MN 55356 !"' <br /> Total Fee: z� n -- , W,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: 332.. West- (a. ce St. Lo- La-k( , (v\NJ 553S(0 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other-Display Home? ❑ Yes E 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 serv"ibe 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: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: ' civ .CIACLA c C-► -- V\ - AC�1�G tA)01 { r aQ 2e nkSti fah <br /> Phone (day): 715-14q9-i3-1 g' <br /> Address: 3,32 We6A--- LA-r---e S�-• City: Lan <br /> 1.4_1(.4._ ZIP: 55 35-L, <br /> Email and/or Fax: je-i,‘n �J <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD)El Re roof,asphalt Re air ❑ Storm Damage <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> 0 Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ < CI cecs <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 application may not be issued. <br /> Applicant's Signature: Date:r <br /> Owner's Signature: Ali �' 661/talik i - (�� Date: 2_ - 1-1-lb <br /> Last Updated:January .iIIN� <br />