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, . ` City of Orono �2� � � Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) ,--- / O�A, MaiJing Address: � � 'v� PO Box 66 Permit number: r� � Crystal Bay, MN 55323-0066 Date received: � a ,,� StreetAddress: Received by: yF ` G:. 2750 Kelley Parkway Plan review fee: �7�rsNo�� Orono, MN 55356 Main: 952-249-4600 Fax: 952-249-4616 Total Fee: www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL tNFORMATION: , Job Site Address: ? " �, � 'r ' � ' �' `�� � d,�—�.,f- �.,.�-T1'-�' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes lfyes,a special event permit is required with Police Department and Cit Council a � required unless applicant demonstrates su�cient on-site parking is availableal No�permitted events willtnot be allowed.ervice will be CONTRACTOR/APPLICANT INFORMATION: Name: -��-�-� �� State License# � � (� Expiration Date: Lead Certification Number: � �s �_._. Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) (office) 6 — �'� � �� Mailing Address _ ��f5� �e1��; c - � _ 3S Contact Person: �� C�ty� � � Z�P� - � �-- ►JN Applicant is: Conr t�rac_tor / Homeowner (Clrcle One) Email and/or Fax: PROPERTY OWNER INFORMATION:,., ' Name: (J"�'.�� `��T-IC�LP-��--j Phone (day): �-j_>,�? `f 7b ��,5�y Address: ��qt�j ��?-�•-L/ C�1�'� � City� (��j'�-J Z�p Email and/or Fax: PROJECT INFORMATION: Overall ro'ect descri tion: Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8,permits: �e-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, cedar ❑ Restoration 18202 Minnetonka Blvd ❑ Water Damage Deephaven, MN 55391 ❑Re-roof, other(specify) ❑Siding ❑ Other: (specify) Phone: 952-471-0590 ❑Window(s) Fax: 952-471-0682 www.minnehahacreek ora Estimated Construction Valuation of Project(excluding land) $ , - ----- 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 alternative but to reject it until it is complete; • Some or all of the information 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 �ner ly cannot be given to either the public or the subject of the data. Our purpose and intended use of this infor tion i;�to arinuall update our records and records of other govemmental agencies required by law. If ou refuse to s I the i rmatton,th�a 'cation ma not be issued. ApplicanYs Signature��-- ��_ ,� ..,,,��'��,� Date: ��' � `f�— ( Owner's Signature: Date: Last Updated:D3/0612013