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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 /> OA, Mailing Address: Permit number: D 16- vU 5i <br /> `VO PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �� cJ <br /> Street Address: Received by: <br /> Z 2750 Kelley Parkway Plan review fee: �( f\ <br /> F L Orono, MN 55356 <br /> 11kESHow" <br /> Total Fee: ' 5► 12 (o <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us `t J <br /> This application form must be completed in full and all required information must be submitted. U� d <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: ' 11 / LrvtscT 515/11— <br /> Job Site Address: ??3r c" / /i�j (>,2S 71" ]'wk. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes ,allo <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: je m A 1.-7., t° u el d /4i 6 s <br /> State License# /GC - /g 2- 9 8 l Expiration Date: 3 31/a 2/ 7 <br /> Lead Certification Number: Aid 770 c.,/5,4,5-/ Expiration Date: frq/Q , /7, 020/ <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell), /02 - 757_a pp , (office) . r C <br /> Mailing Address: !a ke.EK[Jv e,o D .57-.. city:e i-Sk 63 ZIP: �5,3/ <br /> Contact Person: p/./ Lv ti(. Applicant is: ontractor / Homeowner (Circle one) <br /> Email and/or Fax: ton&A7' c.>'1 - /40 7 ,r101-/• eow, 15-.2 — Lj 7 c1/- 3(/`/0 <br /> PROPERTY OWNER INFORMATION' <br /> Name: ,A R-J 1,1401/a <br /> Phone(day): ,(/a- - y/q �/ <br /> Address: 9?3 tc' C D/fv 2 S r '7" City: )/Lrt C)DZIP: ,3'-?-3Email and/or Fax: 46/y gyp- 1 /Z/�/L✓4`�• bi Z <br /> PROJECT INFORMATION: Overall project description: / � 4" / , �j 4 rn r - ,LS l ai-rw <br /> Type of Project: Any earth movement may also requite <br /> 'Door(s) ,Remodel 0 Fire Damage MCWD review&permits: <br /> ❑ e-roof,asphalt E] Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration 0 Water Damage Deephaven,MN 55391 <br /> ❑ Re-roof,other(specify) 0 Siding 0 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) $ $, COO <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 othergovernmental agencies required by law. If <br /> you refuse to supply the i ormation,th applicat may not be issued. _ <br /> Applicant's Signature: V � %y Date: I / 21D/5 <br /> Owner's Signature: ` ,id: 70, ..1 . ...--- <br /> T a-?'-1 Date: /to <br /> r f <br /> Last Updated:January 2015 vJ <br />