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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: U <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a Street Address: Received by: <br /> ti G� 2750 Kelley Parkway Plan review fee: <br /> F <br /> kESH��� Orono, MN 55356 <br /> `g <br /> Total Fee: I UQ•�� <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 INFORMATIO <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ 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 s rvice 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: -C-- LA(_T)E(2S <br /> State License# Expiration Date: -5S 3 <br /> Lead Certification Number: �c:�q L4 ' _ Expiration Date: ZD <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (0 Z-7 Z_0 "_ q9-2_B (office) <br /> Mailing Address: 'Eol ' > City: INS ZIP: <br /> Contact Person: L )uV26<_7uC_ Applicant is: ont / Homeowner (Circle One) <br /> Email and/or Fax: r I'�EGD(5�✓t TiL,i L>6R2;M til 6F GI`A-A 1 L_.GoM <br /> PROPERTY OWNER INFORMATION: <br /> Name: —FCE Bw , G(© ©US <br /> Phone(day): [ ( _ C5 _ C;S <br /> Address: I L4 C)s )(Emtu n k Lj� City:_}M M(50-9� ZIP: J S Lf4 1 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description:`lu. oyt�� fcx�r- '�rr ik�c� N�GS"�e- <br /> Type of Project: Any earth movement may also require 150 i <br /> ❑ Door(s) �.Remodel El Fire Damage <br /> MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 3 <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: _y im Date: r I q Z1 <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />