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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 /> �O . ` Mailing Address: Permit number: �� <br /> l��O PO Box 66 _ <br /> Crystal Bay, MN 55323-0066�� Date received: --/ <br /> Street Address: � Received by: <br /> y�, � 2750 Kelley Parkway (P���� Plan review fee: <br /> ��kFs H�Q`�. <br /> L Orono, MN 55356 <br /> Total Fee: � �� � g � <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 /> Job Site Address: G ��,�, Y-� � -( "1 ;�C.1-�; <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o <br /> /f yes,a specia/event permit is required with Po/ice Department and City Counci/approval 60 days prior to the event. Shutt/e bus se ice wi//be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permrtted events will not be allowed. <br /> CONTRACTOR/APP I�ANT I FORMATION: <br /> Name: —' lJ� �'vt �1�t�1PS <br /> State License# Expiration Date: �-- 3 � — �� <br /> L-���+����^^�ie� N��mhp�� 1 �� y� Expiration Date: —�^ <br /> (for work on homes fhat were constructed pr�or to 1978 <br /> Phone: (cell) - � -- " � �' (office) <br /> Mailing Address Q !" ; City: ZIP: <br /> Contact Person: � Applicant is: ra / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER IN ORMATION: <br /> Name: `� ` <br /> , <br /> Phone(day): � y�3 � 7 <br /> Address: � ��,�,F� City: ,-�.c� ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Remodel ❑ Fire Damage <br /> MCWD review&permits: <br /> ❑ Re-roof,asphalt Repair Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> � ---_1�Minnetonka Blvd <br /> ❑ Re-roof,cedar Restoration ❑Water Damage �e onka, MN 55345 <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) $ <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 he information,the a lication ma not be issued. <br /> Applicant's Signature: ^ Date: �� Z ��� ` � <br /> , <br /> Owner's Signature: ; Date: �a ' 2 15 – � � <br /> Last Updated:January 20 6 _ � .�'�' <br /> � � � �, ,/�� /'f�, <br /> � � <br />