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• <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, daors, siding, re-roof, etc. — NC3 STRUCTURAL EXPANSiON� <br /> �0�� MailingAddress: Permit number: � C`�—� c � <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: C�— �7 /s <br /> Street Address: --- Received by: �� <br /> ..._._ - <br /> �� � 2750 Kelley Parkway w� Plan review fee: ��0• <br /> t,yk�S�o,��G Orono, MN 55356 __ s'_ ` � <br /> Total Fee: / 3/ 3� --.— <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ! � � � �/8j� <br /> This application form must be completed in full and all required information must be mitted��wv�`�/ <br /> Incomplete applications will be returned. (Please print)� <br /> GENERAL INFORMATION: i + r <br /> Job Site Address: LI 1�-- l�1 V� �'1 St�V{\ � �- <br /> Will this be a Parade of Homes, Remodelers 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 s ice 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: S.�ne,�'��,,, (�,,,; Ic��'S L�C <br /> State License# �L ba �(�� Expiration Date: 3 �f � <br /> Lead Certification Number: NA�- � (pb �p�-� � I Expiration Date: 3�Z� ��, <br /> (for work on homes thaf were constructed prior to l978 <br /> Phone: (cell) �o�Z-���� — y �� � (office) (�(Z �'� � — _ '�-� p <br /> Mailing Address: p� �, "�`�` City: (�p� S- ZIP: S�v\ <br /> Contact Person: � � Applicant is: Contrac r / Homeowner (Circle One) <br /> Email and/or Fax: c�L�.�C���y�QJ�1����n��c�t:�5 , ,�L;f� �Z- -��`ZD � �' <br /> PROPERTY OWNER INFORMATION: <br /> Name: (���-� �.i���c�N <br /> Phone(day): �Z_ 2 � '��' <br /> Address: �'�Z�L Li�nh n City: w�, ,� ZIP: � �� <br /> Emailand/orFax: m�-�-}-j.�,,,,�, , c�boc�c� _^Cf��`o6�\nS��n , Lor-h <br /> PROJECT INFORMATION: Overall ro�ect description:� �� �Ce. (�i��n-.�°� � �+ t � ��!' �j���'�j�,e� <br /> Type of Project: Any earth movement may also require � <br /> ❑ Door(s) ❑ Remodel 1�4,Fire Damage MCWD review&permits: <br /> � Minnehaha Creek Watershed District(MCWD) <br /> e-roof,asphalt �Repair ❑Storm Damage <br /> J � 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 /> Estimated Construction Valuation of Project(excluding land) $ l <br /> S�'G C�r►�✓�LC <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 govemmental agencies required by law. If ' <br /> ou refuse to su I the infor tion the a li ation ma not be issued. � <br /> Applicant's Signature: Dafe: �� �.� <br /> ,/� L <br /> Owner's Signature: �" = -�� Date: �� � � I J <br /> Last Updated:January 2015 j <br />