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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: 020/ – Q <br /> ��,0,�.\ PO Box 66 G� <br /> Q :, 0 1� Crystal Bay, MN 55323-0066 Date received: – 7— <br /> ,a i v � ;�, �,) Street Address: Received by: <br /> '�'F, , �"^ Gtiti�� 2750 Kelley Parkway Plan review fee: /L'����F' 9-[.Qe c ' <br /> �9k�sx��'� Orono, MN 55356 <br /> ��-� Total Fee: n n <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � �% 7� � <br /> This application form must be completed in full and all required information must be submitted. lf,y�`� -���% 2 <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: �-- � - . <br /> Job Site Address: ' ,� / ) L,( `'C_3._� <br /> Will this be a Parade of Home , Remodelers Showcase e or other Display ome? ❑Yes No <br /> If yes,a specral event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus se " will be <br /> required unless applicant demonstrates sufficient on-srte parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: � � �N . «� <br /> State License# Expiration Date: �j �' <br /> lead Ce�tification Number: - Z -- � Expiration Date: 7 /¢ /(� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: �(p�� ?.2j -���� —fe#frcej cell ' <br /> Mailing Address: � Q City: [��p ZIP: � � <br /> Contact Person: Applicant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax: IJ-�y���a.�,�� 411-e��w�ln.�. ca.v�oc�;�-i'c� . �a� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �pd��--4SW-Tt�l..£�•l �c.�4f-t=►�£U <br /> Phone (day): �j�'`jZ �- g ° � <br /> Address: Z(fltJ � � V�/►� ,�- C�tY� �`IJO ZIP: �"j�j��j-r�-� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overall Project Description: -j� <br /> Estimated Construction Valuation of Project(excluding land) $ � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true 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 altemative <br /> but to 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 /> confidentiai. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generall cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this informati is nu Ily update our records and records of other governmental agencies <br /> re uired b law. If ou 'nfor i , e a lication ma not be issued. <br /> Applicant's Signature: Date: � / � �. <br /> Last Updated: 08-09-2011 <br />