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City of OronoG�- � <br /> Building Permit Application for Maintenance / Renovation �5 <br /> (windows, doors, siding, re-roof, etc.) <br /> 3• <br /> Mailing Address: <br /> CryPermit number: oZC) <br /> O �O Cr Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> : <br /> Street Address: Received by <br /> o 2750 Kelley Parkway �Plan review fee: ?/,/--7. wl <br /> lq� xo$4 Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 0,rV Sf.1 &u.f UniSlikWil (0,mkP 2-7ZS 1VG13W, 0►ro al IU Xn3s(o <br /> Will this be a Parade of Ho es, Remo eters Showcase Home or other Display ome?/Y . YesEl-No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days p►ior to the event. Shuttle bus service wN be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: v f` <br /> State License# "/A Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: ofS ), 4715 511(1 (office) (e !;- 8b$ 6.5;Uq (cell) <br /> Mailing Address: Ci ZIP: IV <br /> Contact Person: Applicant is: onVaCt / Homeowner (Circle One) <br /> Email and/or Fax: a.�nQGhC2�, s fi��ne,r( . poi+'► <br /> CJ <br /> PROPERTY OWNER INFORMATION: <br /> Name: , A CCaan ( mD LG <br /> Phone (day): <br /> fr <br /> Address: % �_ -� 0 city: �ZIP: 3 :vim( <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof,other(specify) ❑Siding ❑Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) s ,., 7j <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: J Date: �� 2 <br /> Last Updated: 08-09-2011 <br />