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. City of Orono <br /> Y Bdilding Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> •10.A/- Mailing Address: Permit number: <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> 4' 2750 KelleyParkway <br /> tie L� Plan review fe <br /> t Orono, MN 55356 <br /> 4kESHO' (cI,0'5 <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 a submitted. <br /> Incomplete applications will be returned. (PIe se print) <br /> GENERAL INFORMATIO C s/6 gq5 w ) ( ) V I ew <br /> Job Site Address: �J LA).)t�Q(A) lar: Ort' <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes []'Flo <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 INFORMATIO -t�,� <br /> Name: ] c v Q � e- I`'QrYlc v1P� �. 1 eco <br /> State License# (>031 Ca� U Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell)* )L - 3q-sbal (office) <br /> Mailing Address: 4.3247/5-1 /p*%,,.,Q C,,} . IN•f. City: 1,‘;„ie ZIP: SS"yti5' <br /> Contact Person: Scc..) Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: Sr-mit. t&Ne QAe_eerKAL i ' (Wok <br /> PROPERTY OWNER INFORMATION: t <br /> Name: kcor cry 4" 1"i Ce 1 \.C\S Yl A <br /> Phone (day): <br /> Address: Sys `tbw g).2. City:e3,-0„0 ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: __ <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) 12Remodel ❑ Fire Damage MCWD review&permits: <br /> CIRe-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration El Water Damage Deephaven, MN 55391 <br /> 11:1 Re-roof, other(specify) Eliding 5+Jct 0 ElOther: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) SQ OtA-o..SI 4F www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ rip4.)4-4) <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 suppl inf ati , application may not be issued. / <br /> Applicant's Signature: 7,......--...... Date: (:.'5--- a D - /c 1 <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />