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. City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O� Mailing Address: Permit numbera�/ •d� <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066� Date received: <br /> Street Address: �/� Received by: <br /> y � 2750 Kelley Parkway C'" � Plan review fee: <br /> F G ���� ,� <br /> t Orono, MN 55356 � <br /> �k�SH��� Total Fee: � �� <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 /> .lob Site Address: 248 Cygnet pl. Orono MN. 55356 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes (� No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Frank GardnPr C�nstructinn <br /> State License# RC;F4F74F Expiration Date: �A <br /> Lead Certification Number: Expiration Date: ��o <br /> (for work on homes thaf w n p ior to 1978 <br /> Phone: (cell) g52-239-0084 (office) same <br /> Mailing Address: .��nQ F ��� �t. City: M I�S, MN Z�P: 55406 <br /> Contact Person: Erik / Frank Applicant is: XContractor / Homeowner (CircleOne) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> rvame: John / Bianca Chance <br /> Phone (day): 612-718-6862 <br /> Address: 248 C�(gnet � City: �.,�n� ZIP: 55356 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: Bathroom remodeling <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) [�Remodel ❑ Fire Damage MCWD review&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 land) $ 14K <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 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 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 the information,the a lication ma not be issued. <br /> Applicant's Signature: frank gardner Date: 10/23/2014 <br /> Owner's Signature: John Chance Date: <br /> Last Updated:03/06/2013 <br />