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� ' City of Orono Building Permit Application for Maintenance / Replacement/ Remodel - Residential ONLY (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) � n A�O Mailing Addnass: Permit number: `� 1��•��V PO Box 66 Crystal Bay,MN 55323-0066 Date received: — � — Street Address: Received by: y�, �� 2750 Kelley Parkway Plan review fee: � G Orono,MN 55356 �x SH�� Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required infonnadon must be submitted. Incomplete applications wtll be returned. (Please print) GENERAL INFORMATION: r Job Site Address: �',,}`2�'{"'j (' ,�,..-3 c o t,�,�,•�„�,Q . �ra.�.� Will this be a Parade of Homes, Remodelers Showcase Home r other Display Home? , Yes No If yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus se►vice will be required un/ess applicant demonstrates su/ficient on-site parking is available. Non permitted events wil!not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: -- -( 11 ��-� State License# � y Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) (office) Mailing Address: City: ZIP: Contact Person: Applicant is: Contractor / Homeowner �c�.�o o�o� Email and/or Fax: PROPERTY OWNER INFORMATIONt Name: �it/�_��c�.n-��R-- Phone(day): Sa� Z3� ��{�'t, Address: 2 H i 3� � City: A .;�"'a ZIP: D O Email and/or Fax: ,,� PROJECT INFORMATION: Overall r 'ect descri tian: ao Type of Project: Any eerth movement may also requlre MCWD revlew 8� ermlts: ❑ Door(s) ❑Remodel ❑Fire Damage p ❑Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) ❑ Re-roof,cedar 15320 Minnetonka Blvd ❑ Restoration ❑Water Damage Minnetonka,MN 55345 Re-roof,other s ec Phone: 952-471-0580 ,� ( p ify) ❑Siding ❑Other:(speaty) ��+�` Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.oro Estimated Construction Valuatlon of Project(excluding land) ; � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all infonnation required or requested by the Building Department; • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responslble for submitting a complete application being aware that upon failure to do so,the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this applicatlon is classified by State law as either private or confldential. Private data is infonnation which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other govemmentel agencies required by law. If ou refuse to su I the iniormation,the a I{catlon ma not be issued. ApplicanYs Signature: Date: _�_.. Owner's Signature: Date: � , � t�� Last Updated:January 2016 "