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� - City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) %' � �, Mailing Address: Permit number: 0 �l� ' �� `� Po BoX ss '� � ��. Crystal Bay, MN 55323-0066 Date received: —o� � i � � Street Address: Received by: t �. �. ; ��;. � � � 2750 Kelley Parkway Plan review fee: ��q� �`' Orono, MN 55356 � �� '�E.S H�� Total Fee: Main: 952-249-4600 Fax: 952-249-4616 wwv✓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 INFORMATION: � Job Site Address: � � Will this be a Parade of Homes, Remodelers Showca e H me or other Display Home? ❑Yes o If yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service will be requrred unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. CONTRACTOR/AP LICANT INFOR TIO � Name: ,,,,./K.��' � ✓ � ;c,�-��-�. State License# � , � — Expiration Date: �-3 � —/� Lead Certification Number: �• � _ �' �� — / Expiration Date: l� �Z — 2 p� � (for work on homes that were constructed prior to 1978 Phone: (cell) � � �_�p C�—�,, v;+�-� (office) Mailing Address: "Gj�,j !� ' .,,._ / Ci � �,�;•,,;`ZIP: S �,j �/ � Contact Person: ,i � , � � �� Applicant is: Contra o ' / Homeowner �c��ie o�e� Email andlor Fax: PROPERTY OWNER I FORMA�ION: Name: E>�,c>w.r ,�L Phone(day): 7�j .— /d�� Address: / � �(� ✓ ,� • �— /7 J City:a�� ZIP: � �� Email and/or Fax: PROJECTINFORMATION: Overallproectdescription: �DD � v •c.- /�ov�S �-%•��'-'-'1' �C'�a� Type of Project: Any earth movement m y also require ,C�� ❑Door(s) �Remodel ❑Fire Damage MCWD review 8�permits: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ��e-roof, cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof,other(specify) ❑Siding ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek orq 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 corred 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 information that you are asked to provide on this application is classified by State law as either private or confidential. Pnvate data is informa� whi en cannot be given to the public but can be given to the subject of the data. Confidential data is infqr�rration c �al not be given to either the public or the subject of the data. Our purpose and intended use of thi�fiformatio s uatl . ate our records and rec:ords of other govemmental agenaes required by law. If ou refuse to s I the info � n, e�a ca on ma not be issued. ; .--__�_ _ 2( —_/_f ApplicanYs Signatei,�e: -- Date: l(�-� __�.__� , �1 � 23 ,1.� Owner's Signature: :' Date: �/ Last Updated:03/O6/201�i '