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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�O Mailing Address: Permit number:
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> Street Address: Received by:
<br /> y � 2750 Kelley Parkway Plan review fee:
<br /> F �,
<br /> Orono, MN 55356
<br /> `�KESHO�� Total Fee:
<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: x v� �o���r /��^^ (.-�,�Z ���� ,�� M ^�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No
<br /> !f yes, a specia/event permit is required with Police Department and City Council approval 60 days prior fo the event. Shuttle bus serwce will 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: /� -1 #��zsF�. -.{,,�..
<br /> State License# �� ;��� i z S Expiration Date: Z�t e
<br /> Lead Certification Number: N�� Expiration Date: N��
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) �, � Z, - ?�-,�, - S�4(� (office) NI/1
<br /> Mailing Address: �� ,a;; ,�� „` ��,.,e N�,�r�. City: �/��,,,�-.� ZIP: s�- %`�e
<br /> Contact Person: �`,,, Applicant is: on ra�cfo J / Homeowner (Circle One)
<br /> Email and/or Fax: 1�t� �w c�- � �t s��,-c _��U„_
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �,,��,��1�, ��y e s
<br /> Phone (day): �i Z - � S"�1- �y� `
<br /> Address: �c;a Fv,,�s� A��, L4�` City: �,,-�,.,,, ZIP: ,� SS��c� Y'
<br /> Email and/or Fax: h,�/�
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�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) $ �, 1�??� .
<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 infor � n,the a lication ma not be issued.
<br /> ApplicanYs Signatur�_�--�- _:--_- - � Date: � �f��/��
<br /> Owner's Signature: Date:
<br /> Last Updated: 03/06/2013
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