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,, ,�,_ � � � R � City of Orono -9X� �1�� Permit Application for Maintenance / Renov tio�q 0 � (windows, doors, siding, re-roof, etc.) R �s ?0� Mailing Address: Permit number: R�� PO Box 66 O ,AJ O 1 Crystal Bay, MN 55323-0066 Date received: I �.�-�� Received by: � � Street Address: � k'' ,�Y_�- �. ,�, ' ' �, .p_Gti 2750 Kelley Parkway Plan review fee: L W��v Orono, MN 55356 9kE3H0¢ Total Fee: �=—� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: 5� � S -� I�, � �/\/1 ✓�� r Job Site Address: � � � Will this be a Parade of Homes, Remodelers Showcase Home or other D'splay Home? ❑ Yes No If yes, a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be requireu urness spplrcar,t demcr,�frutes suff�crer.t or.-srte parkrn�is available. Non-permitted events will not be allowed. CONTRACTOR I APPLIC�,Gt-!�F MATION: Name: �� State License# CDD Expiration Date: / �6/vZ Lead Certification Number: ,j�` — � Expiration Date: p (for work on homes that were cons ucted pri r to 1978 ' Phone: — (office) (cell) Mailing Address: � City: j ZIP: Contact Person: � Applican is: Contractor / Homeowner (Circle One) Email and/or Fax: �'1 PROPERTY OWNE�� INFORMATIO : �� L(� , _ Name: �Y� Phone (day): — -- /') Address: /.��j 11 � �/� City: (/j2,�I'j� ZIP: �� �--- .. Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ( ) MCWD review&permits: ❑ Door s ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) �Re-reof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Phone: 952-471-0590 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 www minnehahacreek.orq ❑ Window(s) Overall Project Description: Estimated Construction Valuation of Pr ct(ex ding land) $ o , °� APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to nnually update our records and records of other governmental agencies re uired b law. If ou refu e su I the inf mati n�th a lication ma not be issued. Applicant's Signature: � Date: � y �( � �� Last Updated: 08-09-2011