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. � City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> �O�O Mailing Address: Permit number: �L �5 �UU��-/Z_ <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: ��2 �!�" <br /> Street Address: �� Received by: � <br /> tiFl G� 2750 Kelley Parkway �'I I)� Plan review fee: ��;/ , � t �(i �'Cii�-- <br /> �kESH��� Orono, MN 55356 � <br /> Total Fee: �/lD, �� <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. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ( _;-' - �:;��=� /,Z`-t-_ ;`�;�, �. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> lf yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle 6us service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: � <br /> (' L�.,�•�L'Ct"-S'`��;:ya Ce_ <br /> State License# /;�1_`� ��� Expiration Date: f��- �-d<��,G. <br /> Lead Certification Number: f,,,�j- �;��y���G. -o Expiration Date: _ 3 <br /> .d- �.�'l� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �� . ���'-/��% (office) �j.J`;' �-�; ��; .. �j%.� <br /> Mailing Address: ���,. ,�Y /°/���/Z �> City:_,'"j'�, �'f�,c ZIP:_;�t��° y <br /> Contact Person: �. � z Applicant is: �-Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �.(��,,�., �.. ,:%;,����. c�r���vj_r<' .CC�«; _. <br /> , <br /> PROPERTY OWNER INFORMATION: <br /> Name: �' ,;��;��:�' .c�>;�J���%c=� <br /> Phone (day): 4ts�- l 7-- ��-�-� <br /> Address: �-�,t' Lr-��'�-� i%CGY�r _ `,I�,��J CitY: �'-CL;.t�s_ ZIP: .���1/ <br /> Email and/or Fax: �T �.;,�.��-rc' � h;;:-��;�.f�������r�<.i C� ,�c;Ert <br /> PROJECT INFORMATION: Overall project description: r J�--`�r ��'��Y�� '� " `�r����� ��-- <br /> Type of Project: Any earth movement may also req re <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) $ `;f ly `�' <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 in rmation,the a ication ma not be issued. <br /> ,"L, ' ," - <br /> ApplicanYs Signature: •�"� � � Date: � .,Z `7` - ��-c:)�-� <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />