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City of Orono �� /c <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, tttLc.) <br /> fqMailing Address: Permit number: of o l , r 06 <br /> W <br /> aPO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: (p'q` <br /> Street Address: Received by: <br /> ti 2750 Kelley Parkway Plan review <br /> Orono,MN 55356 <br /> kf s 97 . 20 <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: 1093 W 1'-.-oiv vi4.),/ 02, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes o <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: etr v&L edAS V._✓e.T2 i /^-, <br /> State License# t3 C_ 3'11 4 Co Expiration Date: 3)3 0S-- <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) '74,3 - t-f- c- 09 S`-f. (office) G -r t <br /> Mailing Address: nl C �,a,�,p �,��►.� City: 01004..1207-4- ZIP: ss'g 7s- <br /> Contact Person: TiAkApplicant is: 0'1—factor / Homeowner (Circle One) <br /> Email and/or Fax: 1,,,,ta act rcm n sfi� f; � .61,,4 <br /> PROPERTY OWNER INFORMATION: <br /> Name: 6.c>5 et- e 2(57�l 4v4 �/c c ic_ w <br /> Phone(day): g ' - 4-7 b - 7 4.2_`( <br /> Address: (o$?0 cu i c.-4-o w V k c 02 City: 6/2-0r-o ZIP: 3 Sle <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) ❑Remodel EI Fire Damage MCWD review&permits: <br /> ❑Re-roof,asphalt _Repair 1:1 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> 0 Re-roof,cedar 0 Restoration 0 Water Damage Deephaven, MN 55391 <br /> ❑Re-roof,other(specify) 0 Siding ElOther:(specify) Phone: 952-471-0590 <br /> AC( <br /> _ Fax: 952-471-0682 <br /> 0 Window(s) t� ' I $ Lw.minnehahacreek.o <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ <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• rma•9n,the application may not be issued. ` <br /> Applicant's Signature: Date: 6/(o%`7" <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />