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� � City of Orono <br /> Building Permit Application for Maintenance / Renovation� � <br /> (w�ndows, doors, siding, re-roof, etc.) ���� <br /> �.-:--= Mailing Address: <br /> ��,�j\ PO Box 66 Permit number: p�0/O�{—� � <br /> /O � o\ Crystal Bay, MN 55323-0066 Date received: .� /` > <br /> / <br /> � � Received by: <br /> ,� '�� �,i Street Address: <br /> '�',�, �� �< � ��'�� 2750 Kelley Parkway Plan review fee: �.$ D <br /> �xE�� Orono, MN 55356 �d�� _p03s <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: � ' � � �� G��o�� �� <br /> Job Site Address: <br /> Will 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 approval 60 days prror to the event. Shuttle bus service will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: /o c.-�� a �a r ��'�- L�- G <br /> State License# C.. C�'7�'� Expiration a e: 3 3 � �/� <br /> . <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 9 �J Z,- 2,0 — '3� (office) (cell) <br /> Mailing Address: t�/ (, ;o� City: $/oY ZIP: ( <br /> Contact Person: w Applicant is: / Homeowner �Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �0�0�'-�, ��,fl�,�1 <br /> Phone(day): <br /> Address: /t.j 9' ��w� Q p� �Q p� City: ��-o,,� v ZIP: 's�(�C-� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ R�model ❑ Fire Damage MCWD review&permits: <br /> / Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ddRepair ❑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: J52-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overalt Project Description: ('� � S V L ,g , <br /> Estimated Construction Valuation of Project(excluding la ) $ � �, .-�j <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is Gassified by State law as either private or <br /> confidential. Private data is information which generalty cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annualty update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to s I the information,the a lication ma not be issued. <br /> �"" <br /> ApplicanYs Signature: Date: � y' <br /> Last Updated: 08-09-2011 <br />