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City of Orono <br /> _ Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> ��,� PO Box 66 Permit number: <br /> O Q� Crystal Bay, MN 55323-0066 Date received: ., <br /> ,� ! `� �.� �, Street Address: <br /> .Rece ve b� <br /> �',�c, � �'���, ,G�/i 2750 Kelley Parkway Plan reviewfee: <br /> \kESH�g� 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. (Please print) <br /> GENERAL INFORMATION: �' � <br /> 1 � <br /> Job Site Address: 1�/—�C-�� �`'�� �l;:).��G� L__�,;�l� <br /> Will this be a Parade of Homes, Remodelers St�o'wcase Home or other Display Home? ❑Yes ❑ No <br /> If yes,a special event permit rs required with Police Department and City Council approval 60 days prior to the event Shuttle bus service wil!be <br /> requi�ed unless applicant demonstrates sufficient on-site parking is available. Non-permrtted events will not be alfowed. <br /> CONTRACTOR/APp�ICANT INFORMATION:.� 4 <br /> Name: ` ) r-- ';'.vi�� �✓'"�C,v <br /> State License# �,�,����r����l�- Expiration Date: ��r���-� ��,�� <br /> Lead Certification Number. �,�i.... �� ���� � Expiration Date: ;�'(,�(G �Q Z��,(L <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: ( �� �1 - , ' (office) (cell) <br /> Mailing Address: � � Cit : � ZIP: � <br /> , <br /> Contact Person: • �� .� Applicant i Contract6rv / Homeowner (CircleOne) <br /> Email and/or Fax: ,;�; � + r <br /> PROPERTY OWNER INFORMATION: � <br /> Name: ' <br /> ���1�L�:� � flr!%��-�7��' � ���--�►+-.�'t'.v <br /> Phone (day): ���.c������f�/, <br /> Address: � " ,� Cit : ZIP: �=;; •�„=;-� <br /> ���1_l.�'/l�t��b ���- y � • 6 <br /> Email andlor Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ( ) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: <br /> ❑ Door s 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 /> ' �� � l�y� www.minnehahacreek.orq <br /> �Window(s) ��'1'U/ ��� � <br /> Overall Project Description: ��� 'ylE: '' y� �. � �;� . � , '� ` <br /> Estimated Construction Valuation of roject(e cluding 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 alternative <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 /> confidential. 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 whi e erally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use o�f �s infor io o nually update our records and records of other governmental agencies <br /> re uired b law. If ou re�se to:§u ati ,the a lication ma not be issued. <br /> , <br /> Applicant's Signature: � - � Date: � �(.� <br /> . <br /> __ ---__�_.__._ <br /> Last Updated: 08-09-2011 ' <br />