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City of Orono <br /> .Quilding Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> O Mailing Address: Permit number: Ql Gl <br /> ��� � �� CrysBtal Bay, MN 55323-0066 Date received: 9�L�— <br /> 1 � <br /> � �" Received b <br /> � �, � � Street Address: g � y� <br /> 'y � ; 2750 Kelley Parkway �� '��� Plan review fee: <br /> Ft �� Orono, MN 55356 • ���'�'� 2z <br /> �Krsri���- � �`; L�� ✓J <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 su itted. ���x„ n <br /> Incomplete applications will be returned. (Please pnnt) � / � <br /> GENERAL INFORMATION: � � �'1 <br /> Job Site Address: � � � ' ` ' � � r� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> If yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service will be <br /> required un/ess applicant demonstrates su�"icient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: (�i__ � t �.�„ ? `�y:����.� ,� /t , <br /> �.. E � `, <br /> State License# �.�,, . :- ..._�,�:-� � Expi ation Date: � - � r _ <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �`;�, _ (office) <br /> Mailing Address: �-, , :,_.., .' , ' r i �J City; .' � , -; ZIP: ;� , '�'� ; <br /> Contact Person: ` ,-;� (,,� ;,<, , (_ Applicant is_�ontractor � Homeowner �c�►�ie o�e� <br /> Email and/or Fax: ^ '� ;,_ , <<_ . i, <br /> PROPERTY OWNER INFORMATION: <br /> Name: ;�1�_�; �- ��.�- <br /> Phone(day): i..��:. -�s t. i_;.� r . <br /> Address: � ;._�� . - � City: ZIP: <br /> , <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 /> p ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District MCWD <br /> ❑ Re-roof,as halt 18202 Minnetonka Blvd ( ) <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑ Siding �f Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) ��:,��� ._ •n'.�, J" ' � • � www.minnehahacreek.orQ <br /> Estimated Construction Valuation of Project(excluding land) $ ` _ � � <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 /> ou refuse to su I the informati n,the a lication ma not be issued. <br /> Applicant's Signature: �- � Date: '�= -- �� = <br /> � .. <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />