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- � �• . _ City of Orono ��� � � � � <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> � Mailing Address: ���-0 <br /> j%�,�,�.� PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: �� Z l <br /> �� ���� �' �� Received b : <br /> a ; �� ;���:_ �, , Street Address: Y <br /> �'�� '� =�„�,a„ �ti� 2750 Kelley Parkway Plan review fee: <br /> �v {'��'� Orono, MN 55356 �/ <br /> kESH��' �� <br /> -- Total Fee: S(l � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us U � <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATIODI�- � r�I <br /> Job Site Address: ,� � C � �j�� �l�C-�' v{��D'�� �l� � �S�C, <br /> Will this be a Parade of Homes, Remodelers Sho case Home or other Display Home? Yes [�]'�Vo <br /> /fyes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service wi/l be <br /> required unless applicant demonstrates sufficient on-site parking is availabfe. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT FORMATION: <br /> Name: j '��•-�- <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNE NFORMATION: <br /> Name: ��,n,��, 4�.5�`�' ��� <br /> Phone (day): �� L �1, .- �J� O - C�,�c�--�'� <br /> Address: 1.�- K �({, � �� L ' `r City:�(j� �IP� ,� <br /> Email and/or Fax 0`� � v U . C�U'r'V� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) [1�'Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar Deephaven, MN 55391 <br /> ❑ Restoration ater Damage Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> �Window(s) www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ �G C>(�j�j '-'= <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information, the a lication ma not be issued. <br /> i <br /> ApplicanYs Signature: Date: �� � o�>' <br /> Last Updated: 08-09-2011 <br />