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. � City of Orono -�a Buildin Permit Application for Maintenance / Replacement / Renovation -��j 9 (No structural expansion. Only windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: �v `�� � �Q PO Box 66 � � Crystal Bay,MN 55323-0066 Date received: � Received by: Street Address: _ 2750 Kelley Parkway Plan reviewfee� �r G� Orono, MN 55356 , / � , 1�kLSH�� Total Fee: ��f� _ Main: 952-249-4600 Fax: 952-249-4616 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 pri� �� GENERAL INFORMATION: r� � � /�� G �/ Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Hom r other Display Home? ❑Yes No If yes,a special evenf permit is required with Police Deparfinent and Cify Council approva!60 days prior to the event. Shutt/e bus servi will be required unless applicant demonstrates sufficienf on-site parking is available. Non-permifted events will not be allowed. CONTRACTOR 1 A�LICANT INFORMATION: Name: Expiration Date: �j � State License# Expiration Date: ! Lead Certification Number� {\j�"T'' Z, '� (for work on homes fhat were constructed prior to 1978 (offiCe) Z,• � � �� Phone: (cell) ZIP: c�ty: �- t pK V� Mailing Address: � � Contact Person: Applicant is: ontracto / Homeowner (Circle One) Email andlor Fax: ' PROPERTY OWNER�FORMATI : �� Name: .� _._._ Phone da �' � � y�' City: ZIP: Address: L � �' � � Email and/or Fax: , h ��I C�I �� , � r ' �� PROJECT INFORMATION: Overall pro'ect description: 1 qny earth movement may also require C�G ` Type of Project: MCWD review&permits: /� ❑Door(s) ❑ Remodel ❑ Fire Damage � Minnehaha Creek Watershed District(MCW ) ❑Re-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd Water Dama e Deephaven,MN 55391 Re-roof,cedar ❑ Restoration ❑ g Phone: 952-471-0590 ❑Re-roof,other(specify) ❑Siding ❑Other: (specify) 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 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. Ptaaseinormation whach gener Ilycannot be gven together the ppblbclobthe subje clof the�dataSuOur purpose and Confidential da intended use of this information is to annually u date our records and records of other governmental agencies required by law. I ou refuse to su pl e�i ation,th " plic 'on a not be issued. Date: Applicant's Signature: Date: Owner's Signature: Last Updated:0310612013