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. Cit of Orono �°� � <br /> Y <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O . `O MailiPg�Bd�d 6s�s: Permit number: 0�0! —C� d�`{ <br /> !V <br /> Crystal Bay, MN 55323-0066 Date received: 7-� �`�� <br /> Street Address: Received by: <br /> y�, G� 2750 Kelley Parkway �I'�`�� Plan review fee: <br /> �, Orono, MN 55356 <br /> � aa,a. <br /> �KESHD 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 /> Job Site Address: �� �����v �"' �G{� . <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ 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 service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP CANT INFORM TION: <br /> Name: �, T- �t � � <br /> State License# � � Expiration Date: 3- 7�( - ((o <br /> Lead Certification Number: ,��'. 22 _ Expiration Date: "�' — ZZ - !S <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � _ 2 - � (office) y _ Z� � <br /> Mailing Address: �� � �� t City: ZI : "� <br /> Contact Person: � � Applicant i . j(Contra Homeowner (Circle One) <br /> Email and/or Fax: � <br /> PROPERTY OWNER INFORMATION: <br /> Name: � � �,��a� <br /> Phone (day): (c �Z - 'Lc.�7- d-7�7 <br /> Address: �'�f�j '(�p�^ dicc� City: 1�'�7� ZIP: �•�,3y� <br /> �? (� '� /pGl� , <br /> Email and/or Fax: �� , / ,�A _ ' �i _ �1 � � ������ /z��`. �� <br /> � ' / <br /> PROJECT INFORMATION: Overall pro�ect descripti� �Ll�� �-� ��67G� r <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&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) $ O B� <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 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 informa' n i to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the' ti ,t lica� ma not be issued. <br /> Applicant's Signature: �" Date: �' Y" � � <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />