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s . <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> OA, Mailing Address: Permit number: p� 3 —D� pv <br /> � f VO PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 5"� <br /> .� � <br /> Street Address: Received by: ---����_ <br /> y � 2750 Kelley Parkway Plan review fe : <br /> `� �'� Orono, MN 55356 <br /> `qkFSN��� Total Fee: l p���,� <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 /> JobSiteAddress: 2y��5 � :�� s;�� Q , v�.i�;��: �✓1 ` <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> If yes,a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required un/ess applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: LEMME�Y1.�Iv �i.^IVy"T. .�ti�=. <br /> State License# B�j�s,i�,a y Expiration Date: ��3� � �.�y,�f <br /> Lead Certification Number: M,4.7 -/2(o3�cf --1 Expiration Date: Z,7 Ju�.J 2ot7 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 763— 224� 2 3100 (o��) S�ME <br /> Mailing Address: 90 7 Co. Rn. I? SE Ciry:�-No ZIP: �5'32g <br /> Contact Person: 70� Applicant is: ontractor / Homeowner (ClrcleOne) <br /> Email and/or Fax: L,E,vtCon�IntL � ��p�?iE►Z, coh <br /> PROPERTY OWNER INFORMATION: <br /> Name: �EF� � Ar.��jR�,A �U u.E�rt_-�o ►�1 <br /> Phone(day): Q52 ..ci��..Q 2D0 <br /> Address: SAHE A-5 A-�3aVE City: ZIP: <br /> Email and/or Fax: �'e��_ ,bencl�,Mctrkexecu��ve . Co�l <br /> PROJECT INFORMATION: Overall ro ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review 8 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 landj $ 55��� — <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 compfete; <br /> • Some or atl 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 subjed of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the informatio e a lication ma not be issued. <br /> ApplicanYs Signature: Date: 3 3U►� I'j <br /> Owner's Signature: /''������7!�' ` -�/ Ir`� - r --` Date: .� � ��� <br /> last Updated:03l06/2013—_��_" <br /> � <br />