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` City of Orono <br /> � Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: I l—��_ <br /> ��O�O Crystal Bay,MN 55323-0066 Date received: _'_�S� <br /> � Received b <br /> � a `�'> a, Street Address: y' <br /> �'��-. <br /> �',�,��'���,.,,�,�°ti`� 2750 Kelley ParkwaY Plan review fee: <br /> f�i'}��' <br /> xo Orono,MN 55356 <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 submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: <br /> Will thls be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No <br /> 1(yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle 6us senrice will be <br /> required unless appl'�nt derrronstrates sulhcient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR!APPLICANT INFORMATION: <br /> Name: �5��/'4 �-' �'i D Jj�t--1 NG !l�C_ <br /> State License# ��DCr, 3 t ( �q Expiration Date: 3 3� C <br /> Lead Certification Number: /�f A:?- —�D,�(p D C'j-..% Expiration Date: �`� ����� <br /> (for wo►k on homes that wene constructed pr�or to 1978 ' �T- <br /> Phone: l��Z °Z7 S Z�b '`7 (office) (cell) <br /> Mailing Address: �����?�C;v���y �2� Ciry:�///fP� QCA�rJ ZIP: -f'j��� <br /> Contact Person: �y��. ��f�//�v-�,� Applicant is: , n ra � / Homeowner �circa on.� <br /> Email and/or Fax: �N�.�c'-5����L L ��'{�i4�-�o. Cr�e� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �'�'� �/Zv/v���� <br /> Phone(day): �5� t�7� 9/3 �✓ <br /> Address: ��� C/i5ct> � /Z� - City: D�UN i.0 ZIP: ����'(! <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) ❑Remodel ❑Fire Damage MCWO review 8 permita: <br /> Minnehaha Creek Watershed Distrid(MCWD) <br /> ❑Re-roof,asphalt ,�Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar �Restora6on ❑Water Damage Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(apecfty) ❑Siding ❑Other:(specify) Fax: 952-471-0682 <br /> �Window(s) www.minnehahacreek.om <br /> Overall Project Descrlption: <br /> Eatimated Construction Valuation of Project(excluding land) s/3,��,�'�' <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required w requested by the Building Depa►iment; <br /> . Certifies that the infortnation supplied is Uue and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no aftemative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this applicatlon is classfied by State law as either private or <br /> confidential. Private data is infamaUon which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of th' information is to annually update our records and records of other govemmental agencies <br /> re uired b law. If ou refuse u the inf ation a ication ma not be issued. <br /> ApplicanYs Signature: Date: g o� 0�01/ <br /> Last Updated: 0&09-2011 <br />