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City of Orono Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY (i.e. windows, doors, siding, re-roof, et — TURAL EXPANSION) �O�O Mailing Address: Permit number: �D��o�' 1�/3 7� PO Box 66 ., ,t Crystal Bay, MN 55323-0�'6T � ( !��' Date received: II>- 7—/� Street Address: Received by: � "=. ' ` 2750 Kelley Parkway C�N OF ORONO Plan review fee: � L Orono, MN 55356 lqKESH�� Total Fee: ! �(P, �7 Main: 952-249-4600 Fax: 952-249-4616 www.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) GE"�ERAL INFORMATION: �^ Jo'., Site Address: c��G� 1 c.i�C��' W�.': this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No l�`yes, a special event permit is requi�ed with Police Departmeni and City Council approva160 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CO;JTRACTOR/APPLICANT INFORMATION: Na�,e: L � `. S1�.�� License# � 3 ,_ Expiration Date: � Lc ' Certification Number: ��-�-, �� C��G� - Expiration Date: � �r work on homes that were construcfed prior to 1978 p Phone: (cell) ' (office) C�t'� �'- ��?j �,�_3� M��:ing Address: r-� �G�3Q .z��,;�1�j� ¢� City: , � �� ZIP: ��'-��Is Cc� `act Person: j 5 . �— Applicant is: � / Homeowner (Circle One) Er :.I and/or Fax: PF� PERTY OWNER INF�RMATION: � Na�,�e� L� �k Gt�G`f Ph�ne (day): ' _ `� . G � Ac' �ess: �3 `Td Fr�� City:p(��1� ZIP: �3'��i Er ,�l and/or Fax: P' .`�"�CT INFORMATION: Overall project description: Ty� of Project: Any earth movement may also require MCWD review& permits: C ^or(s) ❑ Remodel ❑ Fire Damage [ �-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd [ ;-roof.ceda� ❑ Restoration ❑Water Damage Minnetonka, MN 55345 Phone: 952-471-0590 [� ' '.e-roof, other(specify) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 _ �Window(s) www.minnehahacreek.orq E nated Construction Valuation of Project (excluding land) $ �7�! -- A" _ICANT ACKNOWLEDGEMENT: • A;rees to provide all information required or requested by the Building Department; • r��tifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are ly responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to ,;ct it until it is complete; � �ome or all of the information that you are asked to provide on this application is classified by State law as either private or c� ��fidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. C :nfidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and in,�nded use of this infor �tio ' t annually update our records and records of other govemmental agencies required by law. If �;�� refuse to su I th crfor ati , the a lication ma not be issued. _. -----. �/��r Ap; � � �� Signature: ' � Date: Owr 's `'�gnature: Date: Las'. ' January 2016