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� `� City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ,//�O A r MailiPO Bo�66� Permit number: —� <br /> �V� Crystal Bay, MN 55323-0066 Date received: � � <br /> i <br /> � Street Address: Received by: <br /> � .a ; <br /> ;, � � : ; 2750 Kelley Parkway Plan review fee: <br /> f� � Orono, MN 55356 <br /> ����sH��`/ Total Fee: 5�, �� <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: � � g b /���r�q �� <br /> Job Site Address: �� � <br /> Witl this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus rvice will be <br /> required un/ess applicant demonstrates suffcient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I AP�LICANT INFORMATION: <br /> Name: �a��� �.i���er <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �S Z-- �{S`f�$��'S (office) <br /> Mailing Address� � o {-{er-.�{� L LN City: 4 z�,-�. ZIP: 5S�4� <br /> Contact Person: �,0.��� �.�e�l ec Applicant is: Contract r / omeowne �c���e o�e� <br /> Email and/or Fax: �z,ie�le2 �uc.�.o�,C,a�^ <br /> --6 <br /> PROPERTY OWNER FORMqTI N: • <br /> Name: aJ� � �C'. �C-T <br /> Phone(day): $Z.- �Sy-�S <br /> Address: f( 0 ri a l.� C�tY� Zc... Qryr.� ZIP: Ss�`( ( <br /> Email and/or Fax: dz ,� � �oo . Cbr^ <br /> PROJECT INFORMATION: Overall ro�ectdescri tion: ����� ���1 ����Se`� � �aS��P� 6�!��-- f�� � �oo� <br /> Type of Project: Any earth movement may also require <br /> ( ) MCWD review 8�permits: <br /> ❑ Door s �Remodel ❑ Fire Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) wwv✓.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ �0 <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 e information,the a lication ma not be issued. <br /> ApplicanYs Signature: � - Date: �z` ZS'�y <br /> Owner's Signature: � Date: �`�S"�Y <br /> Last Updated:03/06/2013 <br />