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City of Orono <br /> t3uilding Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> � (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANS N) <br /> �O� Mailing Address: Permit number — �� � <br /> O PO Box 66 _ <br /> Crystal Bay, MN 55323-0066 Date received: <br /> � a <br /> Street Address: Received by: <br /> tiF � 2750 Kelley Parkway Plan review fee: <br /> � L Orono, MN 55356 <br /> �K�SH��� Total F �-�' /5 � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ���.Ji v <br /> This application form must be completed in full and all required information t be submitted. <br /> Incomplete applications will be returned. (P/ease print <br /> GENERAL INFORMATION: <br /> Job Site Address: _�'���" Ca�c.►vZ'R„� � � � �J <br /> Will this be a Parade of Homes, Remodelers Showc se Home or other Display Home? ❑ Yes � No <br /> If yes, a special evenf permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I AP,�LICANT INFORMATION: <br /> Name: ,�'p5� ��T�21bJ�S �-L L <br /> State License# �C c� ��U t.,�2 Expiration Date: � - ,3 �_)$' <br /> Lead Certification Number: �U�7-- �'�g' �S� � Expiration Date: /j _���- /�, <br /> 1 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �t 2 22� �{72,� (office) �� 2 2,2,� R 6��} <br /> MailingAddress: /�9C $A�.►�/��c}-12 G,;2,._. C�tY�/^�?�Cc�N �/-�- ZIP: �-t <br /> Contact Person: -�-��� ���-� Applicant is ractn� Homeowner (Cirde One) <br /> Email and/or Fax: ��' �"�c����c�2 �� 1 � <br /> PROPERTY OWNER INFORMATION: <br /> Name: �����_ <br /> Phone (day): �-2 2 �'Z2_ <br /> Address: � ��, City: ZIP: <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 MCWD review&permits: <br /> ❑ Re-roof, asphalt �Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding �Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) 0�� °12�P��2�W� www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 2S'_�o� <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 information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: � `��-�J — I � <br /> ��� � <br /> n <br /> Owner's Signature: � Date: <br /> Last Updated:January 2016 <br />