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, _ City of Orono Building Permit Appiication for Maintenance / Replacement / Renovation (No structural expansion. Onfy windows, doors, siding, re-roof, etc.) �O� Mailrng Address: Permit number: �� O PO Box 66 Crystal Bay, MN 55323-0066 Date received: �D �� 5treet Address: Received by: y ` 2750 Kelley Parkway Plan review fee: F L Orono, MN 55356 �"�kESNo�`�" Total Fee� ��.�� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be compfeted in full and all required information must be submitted. Incompfete appfications will be returned. (Please print) GENERAL INFORMATION: � � Job Site Address: (�J� [��-�i,�f.0�.� ��f �'i�['�(/�f7 Will this be a Parade of Homes, Remodelers Showcase Hom� or other isp ay Home? ❑ Yes �'No If yes, a special event permit is required with Pofice Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wilf not be allowed. CONTRACTOR 1 APPLICANT INFORMA„TION: hame: ��v.>�'',��C� � t'X'.cr -F`-.� �i�l'. State License# (�G b�,�� .:Z� Expiration Date: �2� � a�(� Lead Certification Number: ►��,�k--.��;�,, _ � Expiration Date: (for work on homes that were constructed prior to ?978 Phone: (cell) ',.j _ _ S (office) Maifing Address: S,� � ;z � � r City: L.�� ( .; ZIP: �- �� Contact Person: j � G �� Applicant is: onfra� T_� Homeowner (Circfe One) - � C2-�-1'�1' '2� ----.____.____.--- Email and/or Fax: �-� > e�- ' '( . : PROPERTY OWNER INFORMATION: Name: �Y,� I'P-f�P(�.��- Phone (day): 101aZ - 7�C� •-.7��a Address: C �, � ��H�mYr;�°n �;-�- City: �jr�� ZIP: Email and/or Fax: PROJECT INFORMATION: Overall project description: i ype of Pro�ect: 'I Any earth movement may als6 require ❑ Door(s) �emodel ❑ Fire Damage MCWD review 8�permits: ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 [�'�Nindow(s) :>�ULi_t') www.minnehahacreek.orq cstimated 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 solefy 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 applicafion is classified by State taw 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 generally cannot n to either the public or the subject of the data. Our purpose and intended use of this inform tion is to annually upda our re ds and records of other governmental agencies required by faw. If ou refuse to su I the i,"form�tion, e lic ' '� no� e issued. Appficant's Signature: G �� Date: ��_- �� - jL� Owner's Signature: _ Date: �ast Uodatec 03/06/201�