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City of Orono <br /> • B�ailding Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-raof, etc. — NO STRUCTURAL EXPANSION) <br /> OA' MailingAddress: Permitnumber: ('i(5 •- tYZ%.� <br /> � •VO PO Box 66 � <br /> Crystal Bay, MN 55323-0066 Date received: i " f 3 / `_, <br /> a � <br /> Street Address: 'I i�lj� Received by: �-' 1� <br /> ti�,! ` 2750 Kelley Parkway Plan review f : -- <br /> qK�sr����%� Orono, MN 55356 <br /> Total Fee: � �3 . `p� <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: C.�3S V1 �-������� '�c�. `�JS .3�� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other D�splay Home? ❑ Yes �No <br /> /f yes,a special event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shutt/e bus service wi//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: ��-�� 'u'�,`1-�\\�,� C.���s��v c:�� ;; .-.. <br /> State License# '��, (�^�"� �C,� Expiration Date: � 3 j <br /> Lead Certification Number: �G-f-- ���j'"�o-- Expiration Date: a�3G f � S <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) C�12-S`!�%�l��� (office) " l Z., -S�O � (�� �� <br /> Mailing Address: �g ` � �yY4 _ �„� City: � ,J�l,� ZIP: SS y�/ <br /> Contact Person: 6,.,,� I�"1/�� �� Applicant is� ontractor Homeowner (Cirde One) <br /> Email and/or Fax: ��.^V,,��`�'�t,�tio��o�.��GF,`� L.�;,,,tC� 5-�-� V1 ct <br /> PROPERTY OWNER INFORMATION: <br /> � t <br /> Name: �G�r� S�--a�.io�'� � � ���c. ; ��'1,�� � 1 <br /> Phone (day): (p `2, - �j� �2 -(p 2 S Z <br /> Address: (�� 3�" (� �� .r„�l�,�.�� � City: CJ✓o.�r.> ZIP: S-S� cf � <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 /> 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 /> C��'�-��✓� �,Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ �6 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all inforrnation 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' tion,the a ' tion ma not be issued. <br /> Applicant's Signature: li,�i Date: � <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />