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. � � �� . � � <br /> . 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: � ���b�d`D <br /> PO Box 66 / <br /> � � � � Crystal Bay, MN 55323-0066 Date received: � "" (O — � <br /> � � \ Received by: � �. <br /> � a r, � � 1 Street Address: <br /> ti � �{ �(��� n 2750 Kelley Parkway Plan review fee: ,��� <br /> `� �' ���� � Orono, MN 55356 <br /> lqkESH��� �l <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. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �;, � t-�?, G �- �- � <br /> Will this be a Parade of Homes, Remodelers Sh case 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 INFORMATION: <br /> Name: - ' - <br /> �� � ��� i � �� � <br /> State License# ����j�i���g t� Expiration Date: 3� ,p��- <br /> Lead Certification Number: ti��_ �j� l � _ � Expiration Date: Z�Z� <br /> (for work on homes thaf were constructed prior to 1978 <br /> Phone: (cell) (office) �j5� -�L�1- ?�'a 1 <br /> Mailing Address z,� �,-- G,L� City: �� � ZIP: .S'S 3 �- <br /> Contact Person: `�Qr,,: ,,,� Applicant is: Contractor / Homeowner (CircleOne) <br /> Email and/or Fax: -��,� �,; �^yu-,�r ��„�1.t��+�,��_ , [r; vh <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��i2��� � ��.��-� �-��'►��� <br /> Phone (day): �(��- �iH� - �S7� � <br /> Address: ,���,�� City: ZIP: <br /> Email and/or Fax: Sbvrn,e„� Cv �i�ti'�4�i� .C-�ry�ti� <br /> �e�C� �t. , -� C�;��:���r .� {"t;5�i�'c�E'via�--L. <br /> PROJECT INFORMATION: Overall projectdescription: � + Nf.�n%ir%ti�i � �:f G�,Pi,�[ <br /> Type of Project: ny eart movement may a so require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�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) $ �l, Z��c'`= <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 information,the a lication ma not be issued. <br /> ApplicanYs Signature: ////h�� ��F�'ti'6 � Date: T�� � <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />