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City of Orono <br /> ,l +Building Permit Application for Maintenance / Replacement / Remodel - Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> � <br /> OT Mailing Address: Permit number: 2_ _ l)�VO PO Box 66 ©I <br /> � <br /> �jnl)a-rbsr <br /> Crystal Bay, MN 55323-0066 Date received:'— <br /> Street Address: R b <br /> tie 2750 Kelley Parkwa P �0154D <br /> (o-Z_-g90 <br /> �krs x oRti <br /> Orono, MN 55356 P �� cv`� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) <br /> Job Site Address: I lISS W yt.J prnERE_ 'RoA-D ; VJkYz-.A r-A . MN �5 � <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: ST��C i�.R A- kSSeC_I4ATf_:-_5 <br /> State License# ec-.-bot 3`sp Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (,i2y723 r6g5 (office) 952-3q(,-2_1/99 <br /> Mailing Address: t 3tZ t^tlwilirvro p: City: LAX ZArA ZIP: 5-5239 <br /> Contact Person: Ki p Sc+ti20 Applicant is: ontrac o / Homeowner (Circle One) <br /> Email and/or Fax: k 5c h;r,o l ��{re�herh6meS, c�t�r� <br /> PROPERTY OWNER INFORMATION: <br /> Name: 'To-rJY 4 1Aib4F_L_E r,ULRZLO <br /> Phone (day): <br /> Address: IISG LyNbffi& C- 'PxA-0 City: LVA-YZ47-A ZIP: 5539/ <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: ��`t <br /> Type of Project: Any earth movement may also require <br /> ❑ Doors MCWD review& permits: <br /> ( ) Remodel El Damage <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> El Re-roof,cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka,MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project (excluding land) $ / '75,000 <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 thq information, pplication may not be issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />