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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: i' �� '� PO Box 66 � � ` Crystal Bay, MN 55323-0066 Date received: 1 ! , ` � Street Address: Received by: � `� 2750 Kelle Parkwa ' ' . Y Y Plan review fee: �\`�� ' � Orono, MN 55356 `�k�5 t{��t� Total Fee: Main: 952-249-4600 Fax: 952-249-4616 �n^✓�� ci orono rnn_tas This application form must be completed in full and all required information must be submitted. Incomplete applications will be retumed. (Please print) GENERAL INFORMATION: �- , �.(�� 3G� I Job Site Address: �2�C ��"1 �^� D►'�� ` ��0� �-"�-` " ` Will this be a Parade of Homes, Remodelers Showcase Home or other Display ome? Yes No !f yes, a special event permit is required wifh Police Department and City Council approval 60 days prior fo the event. Shuttle bus servic will be required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted everrts will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: �JQS � -��p r5 �� l�S State License# �L y Expiration Date: 3 - 3� - � Lead Certification Number: ,4-T_ 3 0 3�l S— � Expiration Date: �'- S'- � S' (for work on homes that were constructed prior to 9978 Phone: (cell) �� -Z _�1_�-(7�g (office) 7(�3 -- �-{-��- Cj (P MailingAddress: S CGt�ry,p�',Q C C�tY� � ��P� 5S 3 (� Contact Person: �,1� .�- /�V�,�,( Applicant is: ntrac or / Homeowner (CircleOne) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: �� v►��./ �U�'1�'lSa� Phone (day}: crc� �. � � _. o��-� Address: �2�p '�'y�� p��Y- Ciiy:�,V�,-{� ZIP: -�j S 3� ' Email and/or Fax: ' PROJECT INFORMATION: Overall ro�ect descri tion: �� " V(G- ��' � Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review 8 permits: ❑Re-roof, asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd Re-roof, cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof, other(specify) ❑Siding ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) f✓ww minnenahacreek ora Estimated Constnaction 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. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this infor tion is to ann ly update our records and records of other governmental agencies required by law. If ou refuse to su I he i f rmati ,th I� a n not be issued. Applicant's Signatur . Date: �(� � �� "' �_� Owner's Signature: Date: