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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 /> CoA Mailing Address: Permit number: t/7 �Z,(--) <br /> O PO Box 66 / // <br /> (4Crystal Bay, MN 55323-0066 Date received: b/ <br /> a <br /> Street Address: Received by: <br /> 1. G� 2750 Kelley Parkway Plan review fee: I he I Lick- <br /> ! Orono, MN 55356A. <br /> -4ESHO- <br /> Total Fee: ' 0� • (F <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 0 <br /> This application form must be completed in full and all required information must be submitted. . Ln/1 <br /> Incomplete applications will be returned. (Please print) `f <br /> GENERAL INFORMATION: ,rt <br /> Job Site Address: /o 3 0 (,�, 1/0(J Vc.-e 4J ,Qr vc- Lc, t 4 i /( 5 S 3S 6 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? E Yes Et 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/APPLICANTI�NFORMATION:/ I / / <br /> Name: all - rb,‘.1 Corr s/e<scko•, t Re.. me.„ '�1,In a <br /> State License# 15(..- ‘73..? c- Ex ration Date: d yAl'y/ 20/ 7 <br /> Lead Certification Number: NAT-F15-,/S..3 ?-/ Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) ‘/2 - 9,‘ 02 '7? (office) Ce 01 <br /> Mailing Address: /rg '/ /i'l e's„ sr iu r City: /40,4 L94 ZIP: 3-53o1- <br /> Contact Person: ii,j,24Q,/ L.4 j Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: ry,'I(-Q ,, Z ,,,QA. . 6f4,,.1, 60,,-1 <br /> PROPERTY OWNER INFORMATION: `` <br /> Name: 4gpnorl lJebe, <br /> Phone (day): `f5-2- r 8V - l ct <br /> fl <br /> Address: /03° 64): cx Ue,'�. City: Lo ii L4(--c. ZP: s-3-3 S^6 <br /> Email and/or Fax: / <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) EJRemodel 0 Fire Damage MCWD review&permits: <br /> 0 Re-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> 0 Re-roof,cedar <br /> 0 Restoration 0 Water Damage Minnetonka, MN 55345 <br /> 0 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) $ 3 VV.00 <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: l), Date: S,/3//20/-‘ <br /> Owner's Signature: AllkiLed Date: c7/ 1 <br /> Last Updated:January 2016 <br />