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��ECEIVED <br /> , pEC 2 0 2016 <br /> Building Permit Application for Maintenance/ Replacement/ Remodel — Residential ONLY <br /> CITY OF ORONO�i,e.windows, doors,siding, re-roof,etc.—NO STRUCTURAL EXPANSION) <br /> �j�� Mailing Address Street Address FOR CITY USE ONLY <br /> � •� P.O.Box 66 2750 Kelly Parkway aate Received: ��I' /�b—�� <br /> Crystal Bay,MN 55323 Orono,MN 55356 Permit�i �D � �o—D l 'J—S� <br /> � <br /> ,� �pproved By: �`��_ <br /> y � Phone:952-249-4600 Fax:952-249-4616 <br /> �' G�' . PMan Revie+M$: � <br /> �'�x�swc���' Website: www.a.orono.mn.us �?� � �� <br /> �/� c� <br /> Amount$:; J�� ! <br /> This application form must be completed in full and all required information must be submitted. � <br /> Incomplete applications wlll be returned. (Please prin[J <br /> GENERAL INFORMATtON. � � /� ' ,,� �� �,7 A i <br /> Job Site Address: �, �' <br /> Witl this be a Parade of Homes,Remodelers Show e me or other oisplay me? Yes • IYo <br /> fJ yes,a specla!evenL permit is reqttlred w}ih Fo1lce pepartrrterrt an `Ltty touncil approval 60 doys prior to the event.Sl�uttfe d servke w�lf 6e requr'red unkss <br /> applicant demonstrotes sufficient on-site porking is avoilable. Non-permi[ted events wil!not be allowed. <br /> CONTRACTOR/APPUCANT INFORMATION: y <br /> Name: � ��„ �� t � <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) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (ClrcleOne) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: � �v <br /> Phone(day): .. � � <br /> Address: � t City: ZIP: . ,, <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑Fire Damage <br /> MCWD review&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) ��i�,�'��� " wwtiw.mf nehah creek.or <br /> Estimated Construction Valuation of Project(excluding land) $ � = ; <br /> APPLICANT ACKNOWLEDGEMENT: Q <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 solely <br /> responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to reject it until it is <br /> 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 confidential. Private <br /> data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information <br /> 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 <br /> update our record d records of other�pv rrrme at agencies required by law. If you refuse to supply the information,the application may <br /> not be issued. <br /> Applicant's Signature: ' Date: _��� ��(�'1�� <br /> Owner'S Signature: " Date: �t'� �`(„���..� <br />