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City of Oro 0 Buildi.n� Permit Application for Maintenan e / Replacement / Renovation � (No structural expansion. Only windows, doors, siding, re-roof, etc.) �O�O Mailing Address: Permit number: PO Box 66 Crystal Bay, MN 55323-0066 Date received: � Street Address: Received by: y � 2750 Kelley Parkway Plan review fee: `� L Orono, MN 55356 �qkFSHo��` 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 req ired information must be submitted. Incomplete applications will be retur ed. (Please print) GENERAL INFORMATION: Job Site Address: � — ��2 � � . Will this be a Parade of Homes, Remodelers S owcase Home or ot er Display Home? ❑ Yes o If yes, a special event permit is required with Police Department and City Council app val 60 days prior to the event. Shuttle bus ervice will be required unless applicant demonstrates sufficient on-site parking is availa le. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: � ��7`� -�l � .c �� c , State License# � L; �j � � Expiration Date: , - Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) � �,?- 7 ; -- Sl5— i(offi ) w �1 � l G�- �S l S� Mailing Address: �� L� �� Cit f �.c-��v� ZIP: � Contact Person: �� t-�-� r��--�� App,ican is: ontractor ' Homeowner �c��ie o�e� Email and/or Fax: � PROPERTY OWNER INFORMATION: ' Name: �� __�� , r - i Phone (day): ��- ��/v� _ Y S^�S� ' Address: City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) � 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof, other(specify) �iding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ r ✓ � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Dep rtment; • Certifies that the information supplied is true and correct to the best ofi his/ er knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that pon 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 ap lication is classified by State law as either private or � confidential. Private data is information which ge erally cannot be giJ�en t the public but can be given to the subject of the data. Confidential data is informatiop. ge r can e given to ei#her e public or the subject of the data. Our purpose and intended use of this inf ation ' o upd 9ur ecords d reco ds of other governmental agencies required by law. If ou refuse to su the infor ati , - ApplicanYs Signature: � Da e: Owner's Signature: Da e: Last Updated:03/O6/2013