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. �1 <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O� MailiPO Bo�r66� Permit number,p�QI�-i —�� 7`� � <br /> 0 Crystal Bay, MN 55323-0066 Date received: /a2 ' �� -� <br /> a <br /> Street Address: Received by: <br /> y� �' 2750 Kelley Parkway Plan revlew fee: <br /> � Orono, MN 55356 <br /> C�'�ESHO4� Total Fee: / �'3. 1� <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: /-+ f (� <br /> Job Site Address: ��,� C��y��'�r r"!.`�ee <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes �] No <br /> !f yes,a special event permit is requrred with Police Department and City Council approvaf 60 days prior to the event. Shuftle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permifted events will not be allowed. <br /> � <br /> s <br /> CONTRACTOR/AP LICANT INFO�MATION: � <br /> Name: C 2i''� � �C��• t � " <br /> State License# � ' (p Expiration Date: � � � <br /> Lead Certification Number: ��aUj3O��J Expiration Date: /j � <br /> (for work on homes that were consfrucfed prior to 1978 ; <br /> Phone: (cell) (office) y�� - 7 7- (���� F <br /> Mailing Address: (j " �� p � � � Cit : ._ �� ZIP: � ' � <br /> Contact Person: ' U � � ' � y�.� Applicant is. Contractor / Homeowner (Clrcle One) <br /> Email and/or Fax: � j � ��ry��y�� SC�� Y-er�"OS �n�'✓� � <br /> � <br /> € <br /> PROPERTY OWNER INFORMATI N: <br /> Name: �z � �Q( � € <br /> Phone (day): (p (' . ' ' _ (� ( <br /> Address: _ S-�-a� City: (�Vpl�J� ZIP: � <br /> Email and/or Fax: <br /> - , . , ` � <br /> PROJECT INFORMATION: Overall ro'ect descri tion: � ��C. OI,CLS �S� C 2 �,�`S � <br /> Type of Project: Any earth movement may also re Ire <br /> ❑ Door(s) MCWD review&permits: <br /> ❑ Remodel ❑ Fire Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof, other(specify) ❑Siding ❑Other: (specify) Fax: 952-471-0682 t <br /> Window(s) www.minnehahacreek.orq � <br /> Estimated Construction aluation of ProJect(excluding land) $ <br /> � <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> t <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 /> � <br /> reject it until it is complete; F <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 /> confldential. 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 information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I t inform tion,the a lication ma not be issued. <br /> ApplicanYs Signature: � '� Date: � � �� � <br /> Owner's Signature: Date: � <br /> Last Updated:03/06/2013 <br /> ; <br /> & <br />