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s City of Or4no Building Permit Application for Maintenance / Replacement/ Remodel - Residential ONLY (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) '� �`� Mailing Address: Permit number: 4��N� Po BoX ss % Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: y�, � 275U Kelley Parkway Plan review fee: `. " Orono, MN 55356 �RkES H n�� Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: \ Job Site Address: �p '�rnn�c�le .�,,,ep,•� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes [�.No If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: �'25►cr nrG-F►- ��n5��'�or 1��- State License# �qrL��y Expiration Date: �{��'�� Lead Certification Number: ��T_ F��,o05_, Expiration Date: 812��2��,g (for work on homes that were constructed prior to 1978 Phone: (cell) � 1 �,� � (office) -�� _ 2 Mailing Address: � h. p,�,,� #� � Cit : � ZIP: � Contact Person: � �.� 1 a,, Applicant is.�Contractor�/ Homeowner (Circle One) Email and/or Fax: `--- PROPERTY OWNER INFORMATION: Name: C1�r►-.-tu��r ��n� Phone (day): g.s2_y�'��. OL�� Address: c19 �v n�� C:�� City: �-�r, ZIP: c��q� Email and/or Fax: PROJECT INFORMATION: Overall project description: �1 � o�r, Type of Project: An earth movement may also require �Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ 1 LDS. � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data s informatio which generally cannot be given to the public but can be given to the subject of the data. Confidential data is in(ormation which g nerally cannot be given to either the public or the subject of the data. Our purpose and intended use of this nformation is to a ual!y update our records and records of other governmental agencies required by law. If ou refuse to su I the information, e a lication ma not be issued. ApplicanYs Signature: �� Date: �o�-1�ly Owner's Signature: Date: Last Updated:January 2016