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. a,,,�--- I��k�- �-i-l3 <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. On�y windows, doors, siding, re-roof, etc.) <br /> �O • Mailing Address: Permit number: 0�0��j�b(�� O� <br /> nrO PO Box 66 I <br /> Crystal Bay, MN 55323-0066 Date received: �P'�7—�-� <br /> Street Address: Received by: <br /> y ` 2750 Kelley Parkway Plan review fee: <br /> � G <br /> tqkESH��� Orono, MN 55356 pr <br /> Total Fee: � � 7 g �� <br /> Main: 952-249-4600 Fax: 952-249-4616 . www.ci.orono.mn.us 1 <br /> This application form must b� completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: 1- <br /> Job Site Address: I,3`� C-�1�l� Y (' �l u �� �� , C���VI. G ' <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes '�',No ` <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. , <br /> a <br /> CONTRACTOR/APPLICANT INFORMATION: � <br /> Name: ]�/1 D � L�:U1;�'r� �Zc C.• <br /> State License# (�j �, � 3�� 7v � Expiration Date: �_3j -Zv l y <br /> Lead Certification Number. �A•-�-�:_ j Z 3 �c� � - � Expiration Date: L�- c� -�b i 7 <br /> (for work on homes that we're constructed prior to 1978 <br /> Phone: (cell) b I Z—�6 9 -- ���j 3 (office) <br /> Mailing Address: � �-� City: • ZIP: ��3• d <br /> Contact Person: �l � KE, �o� Applicant is: Contracto / Homeowner (Circle One) <br /> Email and/or Fax: J�y�,Ke V OC. K rj �.�►�+-erP�� s�s : �� w, <br /> PROPERTY OWNER INFO MATION: <br /> Name: 1,1�f;I���,, � f�.11��n �e,�tV'a_2ti� <br /> Phone (day): 2 - �y S -1 v� v / <br /> Address: � 3g ���U Y � u 5� �R City: �)j��.,� � ZIP: S S�� I <br /> Email and/or Fax: J <br /> PROJECT INFORMATION: Overall project description: - � � <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �-Remodel ❑ Fire Damage MCWD review 8�permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ (u, vv� ' <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide all information required or requested by the Building Department; <br /> • �ertifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the ' formation,the a lication ma not be issued. � <br /> ApplicanYs Signature: Date: f� ' �Z - zU l 3 <br /> , „� � <br /> Owner's Signature: � Date: � � ��T — �d � � <br /> Last Updated:03/06/2013 <br />