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. City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. – NO STRUCTURAL EXPANSION) <br /> ,-�0�\\ Mailing Address: Permit number: � � � f� <br /> PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: — <br /> �� � � i Street Address: Received by: '� <br /> � �` � 2750 Kelle Parkwa � <br /> �y G. Y Y Plan review fee: � <br /> \� <br /> tq � Orono, MN 55356 <br /> \kcsHo� <br /> ____ Total Fee: 3 � � bs <br /> Main: 952-249-4600 Fax: 952-249-4616 vv �^:�.� ��,rr�n��.�7�n.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: Q <br /> Job Site Address: �o� �16- � J(�jJ�1.� (���I�J� <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. 5huttle bus servic will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORM TAj, ION: � <br /> Name: �N�S1�' �'1 �VZ�`�� <br /> State License # �CG� � �$'� Expiration Date: �- �-�7 <br /> Lead Certification Number: N�.�.. -'Z��� _Z Expiration Date: 3- ZZ _ � <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � - 'Z� -� (office) 3-�y- �j r <br /> Mailing Address: 6 � '+'�1 A� � �, City: ZIP: � <br /> Contact Person: 0 � Applicant is: ntracto / Homeowner (Circle One) <br /> Email and/or Fax: (� ��G � ��C� <br /> PROPERTY OWNER INFORMATION: <br /> Name: � l. ��/1� DC ��__-�►�'�CS `�VLS��� <br /> Phone (day): <br /> Address: ' Z� City: (��� ZIP: �3 <br /> Email and/or Fax: 1- <br /> PROJECT INFORMATION: Overall project description: `_-.�-- -f-�'�( � ��— . �� . ° l. '�1 +„ I <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 /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ 5iding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www i��innNtiali�c��E�k o� <br /> Estimated Construction Valuation of Project(excluding land) $ <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 5tate 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 informati n is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the i rmation,the a lication ma not be issued. <br /> Applicant's Signature: Date: ���J � /b <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 G��'�� (J` /� ��p <br /> �✓'"� `C <br />