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� City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: ��/`j PO Box 66 � Crystal Bay,MN 55323-0066 Date received: Received by: Street Address: � ,� 2750 Kelley Parkway Plan review fee: '�r v� Orono, MN 55356 1'�ktSHo��` Total Fee: Main: 952-249-4600 Fax: 952-249-4616 vuww.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: , �\��I� Job Site Address: -� � C' Will this be a Parade of Homes, Remodelers howcase Home or other Display Home? ❑Yes o If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttfe bus service ill be required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR 1 AP�LICANT INFORMATION: Name: �1 Expiration Date: Fj State License# Expiration Date: l Lead Certification Number: � - � (for work on homes that were constructed prior to 1978 �p�Ce) • ' � �� Phone: (cell) s pK, ZIP: � r City: Mailing Address: � Contact Person: Applicant is: ontracto / Homeowner (Circle One) - - Email and/or Fax: ' PROPERTY OWNER INFORMATIO ( Name: i ��'1 �� J �� Phone(day): _ � City: � �� ZIP. �� Address: Email and/or Fax: � �� � ' � PROJECT INFORMATION: Overall pro'ect description: � ''Y ► �/V� Y ' ` � �' Any earth movement ma so r quire Type of Project: MCWD review&permits: ❑Door(s) ❑Remodel ❑Fire Damage Minnehaha Creek Watershed District(MCWD) ❑ Re-roof,asphalt ❑Repair ❑ Storm Damage 18202 Minnetonka Blvd Water Dama e Deephaven,MN 55391 ❑Re-roof,cedar ❑Restoration ❑ g Phone: 952-471-0590 ❑Other: (specify) Fax: 952-471-0682 ❑Re-roof,other(specify) ❑Siding - �,minne hacreek.or ' Window(s) _��K� ' Estimated Construction Valuation of Project(excluding land) � APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Building Department; . Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. P ta aseinformation which genelr II y can ot be g ve ntoge ther t e p ublbcl obthe subje clof the�dataSuOur purpose and Confidential da intended use of this information is to annually u date our records and records of other governmental agencies required by law. I ou refuse to su I e�i ation,th "" lic 'on a not be issued. Date: Applicant's Signature: Date: Owner's Signature: Last Updated:03106/2013