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r . City of Orono � ��3.� Building Permit Application for Maintenance / Replacement / Remodel ��,�. �arr��r�c��,rs, ��vr�., ��O A'O Mailing Address: Permit number: �O/.5--CT� �� �y PO Box 66 � Crystal Bay,MN 55323-0066 Date received: S —�� 1 I � Received by: Street Address: :. � 2750 Kelley Parkway Plan review fee: �tq �`' Oronq MN 55356 k�}H�� ___ Total Fee: �/Q. �.7 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 retumed. (Please print) GENERAL INFORMATION: Job Site Address: 3U v2 7 C:/-�S C-U ?�1 �� Will this be a Parade of Homes, Remodelers Showcase Nome or other Display Home? Yes No If yes,a special evenf permit is required with Pofice Department and City Council approva!60 days prior to the event. Shuttle bus service wil!be req�ired unless applicant demonsfrafes su�cient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: ` � State License# njG � _�J � � � Expiration Date: ' 3 2�;/ Lead Certification Number. �/'�}r _�� .- I Expiration Date: �/Z`I �20/�, (for work on homes that were constructed p iorr to 1978 Phone: (cell) ��z ��j �) �j„"� (office) Mailing Address: I 5 a ,/��C��..c_£y �Zi� City��PL� �C,�4!N ZIP:��j� �Q Contact Person: �N�� SH��p;�,v Applicant is: Contractor / Momeowner (Circle One) Email and/or Fax: ��,��`€S �> �/tq�.�Z,. �G/�'\ -J PROPERTY OWNER INFORMATION: Name: �"/Ll��l� S"�!}/�'�� Phone(day): ��z �S 3 y o p�/ Address: 3 v Z 5 C-/f S�v (r�T IZ� City: ZI P:�,j�j� � Email and/or Fax: PROJECT INFORMATION: Overall ro�ect description:_ Type of Project: ^ Any earth movement may also require � ❑Door(s) ❑Remodel ❑Fire Damage MCWD review 8 permits: ❑ Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(specifj� ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ['J�Z_��1+ !� _ �Window(s) _________ www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ '�J7 vC3.•"`' 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 altemative but to reject it until it is complete; • Some or all of the infortnation 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 update our records and records of other govemmental agencies required by law. If ou refuse to su 1 the' rmation,t lication ma not be issued. Applicant's Signature: � Date: � Zd/.�� Owner's Signature: Date: Last Updated:January 2015