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. � <br /> - City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> �-- Mailing Address: � <br /> ��,�,�.� PO Box 66 Permit number: �,G � � �- (��Z I(� <br /> /� Q\� Crystal Bay, MN 55323-0066 Date received: I C - ��-1( <br /> i <br /> ''��� �� � y j.�1iC�r� � F� �:_� <br /> �� ' � /" Received by: Zj� <br /> �a `��,�� �,�i Street Address: �_ (� �� Z. I � <br /> ����,�� '���� �ti/ 2750 Kelley Parkw�y��'� Plan review ee: � 2, � S� � S� <br /> �kESH�4j Orono, MN 55356 <br /> -- 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. (P/ease print) <br /> GENERAL INFORMATION: / !�� � ��/ <br /> Job Site Address: �f � I� <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 approva160 days prior to the event. Shutfle bus servrce will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI A T NFORMATION: � <br /> Name: p�-- � � <br /> State License# �� Expiration Date: .- -/Q <br /> Lead Certification Number: � - Expiration Date: `�-�,/-/s <br /> (for work on homes that were cons ructed prior to 1978 <br /> Phone: - _ v� office) ��� - ���-���� (cell) <br /> Mailing Address: � , City: ,�� ZIP:�j�f� , <br /> Contact Person: � G Ap licant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: ��1 �J � �� � � <br /> PROPERTY OWNER INFORMATION: <br /> Name: ���� ���//y� <br /> Phone (day): qs�,- R _ �� <br /> � <br /> Address: ���� � city: ��1D ZIP: <br /> Email and/or Fax ����lr���� � q� � ,� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) �,Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek orq <br /> Overall Project Description: , � <br /> Estimated Construction Valuation of Pr �ect(excluding land) $ 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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I e formation, the a lication ma not be issued. <br /> ApplicanYs Signature: Date: ����l� <br /> Last Updated: 08-09-2011 <br /> l _,, „ C,_._ . L . ..�r,✓�.��- <br />