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. City of Orono Buil�ing Permit Appiication for Maintenance / 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: yF 1 � 2750 Kelley Parkway Plan review fee: t �,�' Orono, MN 55356 � �KESH�� Total Fee: �'�'` � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �"I This appfication form must be completed in full and all required information must be submitted. fncomplete applications will be returned. (Please print) GENERAL INFORMATION: �j � Job Site Address: ��3� f��.�.1�, �� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No /f yes, a special event permit is required with Police Department and City Council approva!60 days prior to the event. Shuttle bus s will be required unless appficant demonstrates sufficient on-site parking is avaitable. Non-permitted events wil!not be allowed. CONTRACTOR/APPLICANT IN,F/�RMATION: Name: �vcY�O� � ��[��!'S �� State License# "�C 3� '�Y S'/ Expiration Date: 03 oy� ��,� Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) '� (o(L� (��(�j- 0�,3 E, (office) �6� Y Z S� ^ ��0 3 MaiiingAddress: t3o� '70 � •�L � City: ! d,,� ZIP: 3C'o Contact Person: �,2�,J So��S�- Applicant is: � ontractor / Homeowner (Cirde One) Email and/or Fax: �q� '76.� �2 S - � ��6� PROPERTY OWNER INFORMATION: / Name: >U A^S� �/6� Phone (day): `�SZ ZaO�O - �v'7 6 Address: City: ZIP: Email andlor Fax: n n PROJECT INFORMATION: Overall project description: K-oa��'� �-��` �� E- �J F ��q�� 'Type of Project: `1 ' �4ny earth movement ay also r uire ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: �Re-roof, asphalt epair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) � 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven. MN 55391 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) ❑Window(s) Estimated Construction Valuation of Project(excluding fand) $ APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Building Departmei • Certifies that the information supplied is true and correct to the best of hislher kr that they are solely responsible for submitting a compfete application being aware that upon fanure to ao so, tne statt nas no aiternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on t � application is ctassified by State faw as either private or confidential. Private data is information which generalfy cannot giv o the public but can be given to the subject of the data. Confidential data is information wh� ally cannot be giv either the public or the subject of the data. Our purpose and intended use of this informa is to annually update rds and records of other governmental agencies required by law. If ou refuse to su I the' ormation,the I ma be issued. AppficanYs Signature: Date: 6 ov 'w/� Jwner's Signature: Date: �ast lipdated: 03/06/20'3