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City of Orono <br /> Bra.�ildirig Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSiON) <br /> A, Mailing Address: •sr , � <br /> �O'V PO Box 66 Permit number. . �;�(� �� C�'� t ' <br /> � Crystal Bay, MN 55323-0066 Date received: � ' - -�3 i ,-� <br /> �,., � � . <br /> � ! Received by: �� _,__ <br /> � Street Address (��� ��"� � . <br /> y�qk�SHOQ'�,L` Oron�o, MN 5356 aY /�I�P- ` Plan review fee: ��� L ,'j • �4� -t� <br /> F � � � ��. <br /> Total Fee: ��� <!,1� <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: 2(o°1a �\\�.I ��1Z. �X�.2,\S�c�� � t�� ��3� <br /> Will this be a Parade of Homes, Remodele s 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 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: -CO.�r1�ic� S,C�,CJ2� <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) ��2_ $G�_ 0l7 1 (office) <br /> Mailing Address: c� City: [�`S•�� ZIP: <br /> Contact Person: -�-� Sr�� Applicant is: Contractor / omeowne (CircleOne) <br /> Email and/or Fax: g«�,M�•� , pi0\• C�aM <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��,.Y�v0. �fe�2.� <br /> Phone (day): ��-L� 4�t�1_ C�IZ� <br /> Address: 2�qal ���v �,� City. C�,\S�� ZIP: Lj�331 <br /> Email and/or Fax: S�e(J2.\rv�pc-�r� (� O�e�l• Cc.� <br /> , ,. <br /> PROJECT INFORMATION: Overall pro�ect description: --�---�'lf�"I' / �`'� �''�'' r x t�=-c1.� ' ' ���` �' � ;j '�;�y�+;�,,�,�� <br /> Type of Project: Any earth moveme may Iso reqyire <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt �Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, cedar 15320 Minnetonka Blvd <br /> ❑ 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) $ 120,l,OD <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. Jf <br /> ou refuse to su I the information, the a lication ma not be issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: Date: or �— �Ol/o <br /> �� ��' <br /> Last Updated:January 2016 <br />