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� <br /> � . . <br /> City of Orono <br /> Building Permit Application for Malntenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: pe�IG number <br /> O,�Q�O PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received- <br /> Received by� <br /> a ,, Street Add�ess: <br /> o� 2750 Kelley Parkway Plen review fee: <br /> ����o�. Orono,MN 5535B <br /> r�i Fgo: <br /> Main: 952-249-4B00 Fax; 852-249�618 www.cf_orono.rn�L-us <br /> 7his appllcation form must be completed in full and all�equlred information must be submitted. <br /> Incomplete appllaations wlll be�turned. (Please prinf) <br /> GENERAL INFORMATION: � <br /> Job Site Addres9: .3 � � C O/ <br /> WIII this be a Parede of Homes,Remod ers Showcese Home or othe.Dlsplay Home? ❑Yes No <br /> If yea,a special evBnt permlt!s rsquired whh Police DepeRment end Clry Council epprovel6o days prior to the event• SAuttle bus seMce wl11 be <br /> �equlred un/ess eppllcanf demonatrates su�ic;ent on•slte peddng Is evailable. Non-perm►tt�d eventa wlll not be allowed. <br /> CONTRACTOR 1 APP C NT INFORMATION: . <br /> Neme: <br /> Stete License# � Expiretion Date: — <br /> l,ead CertificaUon Num er; _ — �� ' Explration Date: — �' <br /> (/or worlc on homes thet wera constructed prior to 1878 �.S r 7 <br /> Phone: . (office) . , <br /> Malling Address: 7� �. G .s C��' �� ' ZIP� <br /> Contact Person: Applicant is: ontre / Homeawner �c�ia o�e1 <br /> Email and/or Fax: � <br /> PROPERTY OWNER 1NFORMAT ON: <br /> Name: ' <br /> Phone(daY): C 2�2 ' � ZIP� s,r 3�� <br /> Address: � t/ C ' C��' � � <br /> Emall andlor Fax . � <br /> PROJECT INFORMATION: � <br /> Type of Project: Any earth movement may requlro <br /> MCWD review&permlt6: <br /> [�Door(s) ❑Remodel ❑ Fire Damage Minnehaha Creek Wetershed Dlstrict(MCWD) <br /> �R�roof,asphalt ❑Repair ❑Storm Damage 18202 Mlnnetonka Blvd <br /> Deephaven, MN 55381 <br /> ❑R�roof,cedar � ❑Restoration ❑Water Damege Phone: 952-471-0590 <br /> []Re-roof,other(apeclTy) ❑Slding ❑Other:(specify) Fax: 952�71-0662 <br /> �W, nehah ek.or <br /> ❑Wlndow(s) <br /> Overall Rro'ect Descri tion; <br /> Estimated Constructlon Valuatiolt Of Project(excluding land $ � O��- O� <br /> ApPLICANT ACKNOWLEDGEMENT: <br /> . . Agrees to provide ell Inlormation reqUl�Ad or requestad by the Bullding Depettment; <br /> . Cert�fles that the Information supplled is true and cflRect to the best of his/her knowledge. The �pplicant recflgnizes that they <br /> are solely responslble fo�submitting a complete appllcation being aware thet upon fallu�e to do so,the staff has no altemative <br /> but to reject it until{t Is co►np�ete; <br /> . Some or all of the informatlon that you are asked to provide on this appllcation is classified by State law as either prlvate or <br /> confidential. Private data Is information which generelly cannot be given to the publlc but can be glven to the su6ject of the <br /> data. Confiden6al data Is Information whlch generslly cannot be glven to either the publlc or the subject of the data. Our <br /> purpose end intended use of thls Information 16 to annually update out reeords and records of other governmental egenciee <br /> I'e ui�ed b law. If ou refuse to I the' tortn � ,the e lication ma not be Issued. <br /> ApplicanYs Signature: Date: ,���� / <br /> Last Updated: 0�09-2011 <br />