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24-�_ 5 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> —� Mailing Address: Permit number: lJl/-0%Z9 <br /> �'gv O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> v <br /> Street Address: Received by: <br /> X!n Gti� 2750 Kelley Parkway Plan review fee: J <br /> L9kES140 Orono, MN 55356 <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: �Q 35 C c- cP©%v,�4 r ✓l0 <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 service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP CANTINFOR TION`: ` <br /> Name: i2�$ Z L <br /> State License # ; Expiration Date: <br /> Lead Certification Number: 6 L -- ` -0o Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 1507)- 3 J _ -i- (office) (cell) <br /> Mailing Address: 3 �P 7 City: �, ZIP: <br /> Contact Person: Applicant is: ntrac or / Homeowner (circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): (�VA- ,Oa-7v2 X73 7 <br /> Address: 3NOA.� �;7��� G.Srn PU�v�� City: 0(^0/NO ZIP: 15531L <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> EJ Re-roof, other(specify) Phone: 952-471-0590 <br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ ,S/" ? wo <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the information,thea application may not be issued. <br /> , - -- -2� <br /> Applicant's Signature: � Date: <br /> Last Updated: 08-09-2011 <br />