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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: ����' �/ � <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: � a� <br /> Street Address: Received by: <br /> y � 2750 Kelley Parkway Plan review fee: <br /> `� �,�' Orono, MN 55356 �D <br /> lqkFSH�� (� <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. � .3Jy,CS <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: t � � <br /> Will this be a Parade of Homes, Remo elers Showcase ome or ther Display Home? ❑ Yes (S�No <br /> lf 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: �C�;G l�� Cs�t���!-, e � <br /> State License# Q C 6 2 Zg�� Expiration Date: <br /> Lead Certification Number: � Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) ��Z_ q�q_�q 8� (office) q,�L-3�( -�q Yq <br /> Mailing Address: Z 5 g� i,� �. P��, City: L �,.� � S�,� ZIP: <br /> Contact Person: $ �.� Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: ��- � ����-}-,,�y„�o���,�,� ,��� y�z 3 b - y�sa <br /> PROPERTY OWNER 1 F RMATION: <br /> Name: �-��,,1 N�,,�'�,�j.t� <br /> Phone (day): � Z Z - 8 � <br /> Address: Z�j� �`(� �, �r City: �G�zG�� ZIP: <br /> Email and/or Fax: ������.��Y� a �( _ �_aw� <br /> PROJECT INFORMATION: Overall project description: '� fti/� � o ��.e <br /> Type of Project: Any earth movement may also 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) $ -f'2, 0�0, o a <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 /> Applicant's Signature: Date: �G�/�h �7 / 7_v/S <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />