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` City of Orono Building Permit Application for Maintenance / Replacement 1 Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: �� l�� ��j PO Box 66 Date received: D �f -/ �` Crystal Bay,MN 55323-0066 Received b : Street Address: � ,� 2750 Kelley Parkway Plan rev e: yt v1 Orono,MN 55356 / �� lqkCSN�R� Total Fe � Main: 952-249-4600 Fax: 952-249-4616 wvuw.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: Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus rvice will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR 1 AP�LICANT INFORMATION: Name: V Expiration Date: '�j Fj State License# Expiration Date: r � Lead Certification Number• nJ�"j"- Z, "� (for work on homes fhat were construcfed prior to 1978 (offiCe) �,• ' ►J �� Phone: (cell) �p�, ZIP: � � City: Mailing Address: � Contact Person: Applicant is: ontracto / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: r Phone (day): ` �l r7 •!�'�. � ' �'�� City: ��V l V ZIP: ��V��y�-� � Address: Email and/or Fax: PROJECT INFORMATION: Overall pro'ect description: �� qny earth movement may al require Type of Project: MCWD review&permits: ❑Door(s) ❑Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) e-roof,asphalt ❑Repair ❑Storm Damage �g202 Minnetonka Blvd � Water Dama e Deephaven, MN 55391 e-roof,cedar ❑ Restoration ❑ g Phone: 952-471-0590 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Fax: 952-471-0682 ❑Window(s) . innehahacreek.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 annually u date our records and records of otf�er governmental agencies required by law. If ou refuse to su pl e�i ation,th " piic' 'on a not be issued. Applicant's Signature: Date: Date: Owner's Signature: Last Updated:03106I2013