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� ' City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) �O ;�O\ Mailing Address: Permit number �l —�l�� �� PO Box 66 ` Crystal Bay, MN 55323-0066 Date received: '��l � Street Address: Received by: ` `� � 1 2750 Kelley Parkway Plan review fee: �tq �� Orono, MN 55356 � Z� �kfS Hc�¢ ._._._.--- Total Fee: �lp �. Main: 952-249-4600 Fax: 952-249-4616 �,�✓t^.�ua.a.orono mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be retumed. (Please print) GENERAL INFORMATION: A n� �� a- 'l �� Job Site Address: 5 y r'1�• Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No tf yes, a specia/evenf permit is required with Police Departmerrt and Crty Counci!approva/60 days prior to tf�e event. Shutt/e bus s r will be required un/ess applicanf demonstrates s�cient on-site parking rs availab/e. Norr�permitted everrts will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: � S State License# 7 Expiration Date: ��?�(�1�_ Lead Certification Number: „ S� Expiration Date: C�'�Sr� (s (for work on homes that were constructed prior to 1978 Phone: (cell) (office) , L��,7� 9(�cj� Mailing Address: �'j' City: ZIP: Contact Person: Applicant is: ontra or Homeowner (CircleOne) Email and/or Fax: PROPERTY OWNER IN RM TIO : Name: �(� Phone(day): a -� � Address: a, � City: ZI P: 3 Email and/or Fax: PROJECT INFORMATION: Overall ro�ect descri tion: � Type of Project: earth movemen ay also require ❑ Door(s) ❑Remodel ❑Fire Damage MCWD revie 8�permits: �Re-roof, asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MC1ND) 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 ❑Re-roof,Othef(specify) ❑Siding ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) �,°,n��w minnehahacreeK.or� Estimated Construction Valuation of Project(excluding land) $ 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 an ally update our records and records of other governmental agencies required by law. If ou refuse to su I he i rmati n,t li ti ma not be issued. ApplicanYs Signature: Date: "" Q— Owner's Signature: Date: