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i � ,�Nc,a,�Q.ed' ��r r/( � City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) �O, `O Malling Address: Permit number: o?d��" �d� �� PO Box 66 - Crystal Bay, MN 55323-0066 Date receivetl: '"��`� Street Address: R�ce(ved by ��, G`�' 2750 Kelley Parkway Plan reviewfee. - - l,�kEs�o��, Orono, MN 55356 - Total Fee: � � �. r�� Main: 952-249-4600 Fax: 952-249-4616 �ntww.ci.orono.mn.us - This application form must be completed in full and all required information must be submitted.. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: .r Job Site Address: � a �J �.l�(�L�'f7 L�17� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes o /f yes,a specia/event permit is requlred with Po/ice Department and Clty Council approval 60 days prior to the event. Shuttle bus se►vlce wll!be required un/ess applicant demonstrates su�cient on-site parking is available. Non-permltted events wlll not be allowed. CONTRACTOR/APPLICANT INFOR,AQATIONi. Name: .��„e � u �,-j State License# Expiration Date: '�j �� Lead Certification Num er: . (�,i"j—' Expiration Date: �' (for work on homes that were constructed prior to 1978 Phone: (cell) (office) y�� -p��7 '��05c� Mailing Address: �O7Sl Ce lp �. Ci : ��S ZIP: ��j�{-3 Contact Person: ��p ��,��p Applicant is: Contra / Homeowner (Circle One) Email and/or Fax: L '��S V►�O V'-Q � SC��1^�e-�''{'JV'c�$ . C � Wl PROPERTY OWNER INFORMATI N: Name: S a A.V ' 6 Phone(day): - Q(�.. 0 � Address: dQ � City:Q`'D`!o ZIP: �j�3(� Email and/or Fax: PROJECT INFORMATION: Overall ro'ect descri tion: 7ype of ProJect: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑Fire Damage MCWD review&permits: ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoratlon ❑Water Damage Deephaven,MN 55391 ❑ Re-roof,other(spectfy) ❑Siding ❑Other: (speclfy) Phone: 952-471-0590 � � �S�l�i ng �0..�t 0 g2,' Fax: 952-471-0682 �doW s _ �� www.minnehahacreek.org Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely 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 complete; • 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 data is information which generally cannot be given to the public but can be given to the subject of the data. Confldential 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 governmental agencies required by law. If ou refuse to su I the'nformation the a li atio ma not be issued. ApplicanYs Signature: � Date: � Owner's Signature: Date: Last Updated:03l06/2013