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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> -WAT <br /> Mailing Address: Permit number:.�_Z�,—[� I D 2 <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �j —�� (�1� <br /> Street Address: Received by: I Y t ) <br /> N. <br /> y� 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> `.kESHO - 13S-7S <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: (7--V:711" ,C54 e( Adz <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/APPLICANT INFORMATION: <br /> Name: ALe o c-cho,-. Ito{-tr_,Si G,Ac--2,(`'s LA-,C- <br /> State <br /> - -C.- <br /> State License# 21--)[..(S 5 Expiration Date: 03/i c <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) Co 2,-.2. -0 ii4 c0 (office) <br /> Mailing Address: (Drit Voile__ City: _ ,,k,� ZIP: 53-3 ZZ <br /> Contact Person: ,,..\,,v, I (.�� Applicanticnis: ontracto7 Homeowner (circle One) <br /> Kc� <br /> Email and/or Fax: e 0 0�:c11'iUr\prvf-- ion, <br /> prof-..e -J ) �v L54.V\ 00 , C 0 cy., <br /> PROPERTY OWNER INFORMATION: <br /> Name: MCA[C (OV\e-'t <br /> Phone (day): (\1,-<1'3- S -L(ct I <br /> Address: -ZVI- Emit'\ Ave City:OioI\c.) ZIP: <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 ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> 01 Re-roof, other(specify) B(Siding R Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) COYNL n' S k ie5 www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ (o)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 t 'nform n the application may not be issued. <br /> Applicant's Signature: Date: (71/ 0/i 3 <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 0, 1 5..,-ua /---1 ti " /iy--,n ,/ <br />