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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> Mailing Address: Permit number: 030/700(770 <br /> OO Box 66 <br /> teCt.r.A" <br /> Q Al1 Crystal Bay, MN 55323 0066 Date received: b---/�/I7 <br /> fr. i r t Address: Received by: <br /> A..;; ,, <br /> \2750 KelleyParkway <br /> ' l Plan review fe <br /> Orono, MN 55356 7:k. �� <br /> �KESHOW �'' <br /> V 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: 1 <br /> Job Site Address: / � ` <br /> ,� . ��a wbc Q(�o))/f'V �.. 3. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Honie? ❑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/APP (CANT INFOR A ION: <br /> N <br /> Name: r3iVy 07s-v <br /> State License# if/el / Expiration Date: <br /> Lead Certification Number: "i/4 Expiration Date: <br /> (for work on homes that were constructed prio to 1978 <br /> Phone: (cell) 323 —‘5-c,?,_ 7 c ) (office) <br /> Mailing Address: 441 Arc tvey/d c,.✓ Dr. City: J t3..NG ZIP:, , D76 <br /> Contact Person: 4div/N Applicant is: Contractor / roil o i own (Circle One) <br /> Email and/or Fax: ja,,,,s„ d` )j (, a e-.1---- <br /> PROPERTY OWNER I FORMATION: r. <br /> Name: c7 0/.. -✓ <br /> Phone (day): 2.3- o F, ,, 8 <br /> Address:. r , ,yievk.✓ b City: b(c-a/4� ZIP: ���--rG' <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ -RemodelMCWD review&permits: <br /> Door(s) DFire Damage <br /> ❑ Re-roof,asphalt Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar <br /> 0 Restoration 0 Water Damage Minnetonka, MN 55345 <br /> Phone: 952-471-05900 Re-roof,other(specify) Siding 0 Other: (specify) <br /> Fax: 952-471-0682 <br /> Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ L.,'",---- :),D <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 info ion,the appl a not be issued. <br /> Applicant's Signat Date: ' / ---/ <br /> Owner's Sign ure: Date: <br /> Last Updated:January 2016 <br />