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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O • MailiPO Bo�r66 Permit number: �JZ�I�—��"�J <br /> �r� <br /> Crystal Bay, MN 55323-0066 Date received: �J !�—/ <br /> Street Address: Received by: �'1'1, <br /> � �G' 2750 Kelle Parkwa <br /> ti�, � Y Y Plan review fee: <br /> t �' Orono, MN 55356 <br /> 1 kEs H°�`�` Total Fee: �Z�, 5� <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: r�35 � �� � <br /> Job Site Address: � <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. Shutt/e bus service will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �' S ' v. L�� <br /> State License# C,g3�pZ'? Expiration Date: �-3)- 2 0!�f <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes thai were constructed prior to 1978 <br /> Phone: (cell) `�52- 5 y O - �/,5O (office) 6`Z- y6z- �O�G <br /> Mailing Address: /53 � KF� �7�'�'7" Cit : �j"A- z�P: 53R <br /> Contact Person: �b r "�,�1 �p.mes Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �b�," 2 Qe�jSiar�rv�ti .CbW+ A`M�.sG� f��Vlslav.YV�►.� • Ca� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �2 V F'�S/.� <br /> Phone(day): <br /> Address: -735 F,�',�,C���� �� N City:�+..d,UO ZIP: <br /> Email and/or Fax: �'�V . F'ISN 2��A.\C. ,Coi'v` <br /> PROJECT INFORMATION: Overall ro�ect description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage 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 /> ❑Window(s) www minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ ZS'�oo <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 the i rmation,the a lication ma not be issued. <br /> ApplicanYs Signature: /(�- Date: 3 -/� '�d/� <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />