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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� Mailing Address: Permit number: 6 {C/ ' �� <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 � � Date received: l�—��— � (o <br /> _,�(�\ <br /> StreetAddress: �� ,�1V � Received by: <br /> y�, G� 2750 Kelley Parkway � Plan review fee: c.P� 9 (.�� <br /> lqkESHO�� Orono, MN 55356 d�/� J �/� <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 g C�� ?�- � <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: _ � <br /> Job Site Address: �-S� <br /> Will this be a Parade of Homes, Remodeler 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-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATI N: <br /> Name: ' � � �( � t% � <br /> State License# ��'�7��,���� Expiration Date: 3 � <br /> Lead Certification Num er: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) G; - -�� - '-� � � (office) <br /> Mailin Address: - C <br /> 9 � City: C �?�O ZIP: � �J C/ <br /> Contact Persorr: �!����� ��r-�;-�.� Applicant is: ontrac / Homeowner (Circle One) <br /> Email and/or Fax: �-T�� � �� --='� <br /> �Gr.�✓1<> �%ii ��'ID�I���r>. ��'S- �('n/1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: (/��U� ��nl 1S�if',S 1i��7 .�r ���f7-��i�i"�l <br /> Phone (day): <br /> Address: /�'�`� �-�-PV� ll���,� �7,r-. City: �1c'��IO 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 MCWD review& ermits: <br /> ( ) Remodel ❑ Fire Damage p <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd <br /> ❑ 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.orp <br /> Estimated Construction Valuation of Project (excluding land) $ (� <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 anraufally update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the information,the a 4ie ' m m �ot be issued. <br /> ApplicanYs Signature: - " - , �""�" KF Date: <br /> ___ .__ �����'/o <br /> Owner's Signature: _ Date: <br /> Last Updated:January 2016�G��,^ � ������ <br /> ri�, � <br />