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. City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O�O Mailing Address: Permit number: �l � <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 n Date received: — p� <br /> Street Address: �� `� Received by: <br /> �� . <br /> y � 2750 Kelley Parkwa � • Plan review fee: 1 � v��.S�] <br /> �lqKFSHa �C' Orono, MN 55356 � � �� /�j <br /> � p, � ��`�� Total Fee: " '�l �^D <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.afono.mn. <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: )Qi ZD }=C� ri ��T�r'��t" <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. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permifted events will not be allowed. <br /> CONTRACTOR/APP�.ICANT INFORMATION: <br /> Name: .��r'�i Li�,�1 �o�,►S�%rZ u c:•7-)o�1 L.v i��/a,�v� <br /> State License# �,� � a -� �-� o y Expiration Date: 3 �1 1 Q; <br /> Lead Certification Number: N �:}•-r— ►�'7 z�7 .-Z, Expiration Date: � Z3 2� <br /> (for work on homes thaf w�re constructed prior to 1978 <br /> Phone: (cell) L}2�3L�--L)1)� (office) �7L 3�t)1)�-53�� <br /> Mailing Address: -�7 Lj 1 V,n�� �r'es r-r ,�}v�-�, N�. C�tY� �'s��-r�. Z�P� 5�v4 d <br /> Contact Person: "DrNN 16 SAti V > G Applicant is: ontrac o�/ Homeowner (Circle One) <br /> Emailand/orFax: ��n.� ;s � �iE'riqcs,nCar���""rv�fi��r� = cor� <br /> �- <br /> PROPERTY OWNER INFORMATION: <br /> Name: �rL�L '�,�y-ToN <br /> Phone (day): <br /> Address: ��2 p Fp,c �vT��3�t— City: �'jgo.�� ZIP: Sr 3 q� <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) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ 1�75';�oo J <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 ' ation,th licati m not be issued. <br /> ApplicanYs Signature: � ��' Date: '7/ZL/l4 <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 ��,'�-„„ � �/(.�FY 6 /� <br /> 7CL <br />