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� <br /> � - City of Orono i�35� � <br /> Building Permit Application for Maintenance / Replacement / Renovation � <br /> � <br /> (No structural expansion. Only windows, doors, siding, re-roof, e c.) � <br />� � Mailin�g�Bd�dre�s�s: Permit number: �� ���� � <br /> p � <br />� � �0 Crystal Bay, MN 55323-0066 Date received: �ao� <br /> ' :�: <br /> � <br /> Street Address: Received by: �� <br /> ��, � 2750 Kelley Parkway Plan review fee: � <br /> �,�' Orono, MN 55356 ,t: <br /> `'�kFSHo� ��� � <br /> Total Fee: , ;� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �_`" <br /> �; <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: � �'��% ��- S"� . � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o � <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 /> � <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: -�-��n1vt�-3-5 �S�:ct�l �:✓L (�z S , 111�C�- � <br /> State License# j�C� ��� �c..�.�..� Expiration Date: 3--�( _ j ,.f � <br /> Lead Certification Number: �� Expiration Date: � <br /> �(for work on homes that were constructed prior to 1978 ; <br /> Phone: (cell) (p I Z- ��°j- �-j�( U (office) Cj�� - �-f 75 -(��7�7 � <br /> Mailing Address: �v � �,}!f- ,q-r/� �.',� �-„� �S'` City: �o � �� ZIP: �'S j� � <br /> r:i Contact Person: ��� a� . �'� �y Applicant is: ontracto / Homeowner (Circle One) � <br /> Email and/or Fax: / T� — '� <br /> �h/��d � ��Afy7�r� 5 /J/"t>� i"[a�?PS. L��/h � <br /> PROPERTY OWNER INFORMATION: � <br /> Name: ��1��YC_ � �/�,?rz s � j Gt��- � <br /> Phone (day): ` i� <br /> Address: ?�(� L�-,¢�- �j_ City: G;;�p,,�M� ZIP: c��� 7� (� � <br /> Email and/or Fax: ����Z,�� ��2 G �5N� GD/�- � <br /> z; <br /> �: <br /> PROJECT INFORMATION: Overall pro"ect description: ;� <br /> Type of Project: Any earth movement may also require <br /> ' ❑ Door(s) ❑ Remodel MCWD review&permits: <br /> ❑ Fire Damage � <br /> P1�' Minnehaha Creek Watershed District(MCWD) � <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage � <br /> 18202 Minnetonka Blvd � <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 � <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 � <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br />�s, Estimated Construction Valuation of Project(excluding land) $ /`S ,L2'��G �' <br /> � � ,;, <br />�- APPLICANT ACKNOWLEDGEMENT: �� <br /> Agrees to provide all information required or requested by the Building Department; � <br /> . � <br />�. • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are � <br />�;y solely responsible for submitting a comptete application being aware that upon failure to do so, the staff has no alternative but to � <br /> reject it until it is complete; ��. <br /> � <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 /> �� <br />' intended use of this information is to annually update our records and records of other govemmental agencies required by law. If � <br />?� ou refuse to su I the i tio ,.the a ication ma not be issued. � <br />��± ApplicanYs Signature: � Date: �� �� "-/j� � <br />#��� � / �'�� <br /> Owner's Signature: U Date: ���� <br />� Last Updated:03/06/2013 ' ���, <br />� �'?� <br /> k_ _ _ <br /> �.,�a <br />