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City of Orono Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: o��/ -�J �0,�. PO Box 66 Q �, O Crystal Bay, MN 55323-0066 Date received: � � �,~`�'��`' Received by: ,a ,"�� ,;�;, �, Street Address: '�',�, � �� % �titi 2750 Kelley Parkway Plan review fee: lyx�Hog,*� Orono, MN 55356 = 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 required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: � � 3 � �� / Will this be a Parade o Homes, Remodelers Sho case Home other Display Home? ❑Yes o ff yes,a special event permit is required with Police Department and City Council approva/60 days prior to the evenf. Shuttle bu service wil/be required unless applicant demonstrates s�cient on-site paricing is availa6le. Non permitted events wil/not be allowed. CONTRACTOR/APPLICANT INFORMAT ON: Name: �+[l �� c• c�n C7lU�� �-. - State License# Expiration Date: � Q Lead Certification Number: ��,�- Expiration Date: /� (foi work on homes at were constructed prior to 1978 �r� �� Phone: _ � � � (office) v��,o �� II ��' Mailing Address: j c n /� Cifi � �� ,� ZIP: � � Contact Person: jy �; plicant is: Contract / Homeowner (Circle One) Email and/or Fax: ,� - � �,,,� ,�� , � �Z�'.��i�-J �Zt� �'�'3,ry� PROPERTY OW INFORMATION: . ,j/� Name: Phone(day): /p�-- G.'` � , "" ' Address: �. � City: � ZIP: � Email and/or Fax ��i�.,�� � PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) oof, asphalt ❑ Repair orm Damage 18202 Minnetonka Blvd ❑Re-roof, cedar ation ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re-roof, other(specify) ❑Siding ❑Other: (specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Overall Project Description: � �,/� � �/it,(/ Estimated Construction Valua ion of Project(excluding d) rf pc�0 ..�T��6,L i 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 dassified 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 update our records and records of other governmental agencies re uired b law. If o refuse to su the information,the a lication ma not be issued. ApplicanYs Signatyx�""""� - Date: ��'' � Last Updated: 08-09-