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City of Orono Building Permit�Application for Maintenance / Replacement / Remodel (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) O Mailing Address: Permit number PO Box 66 � �0 Crystal Bay,MN 55323-0066 Date received: - - __ Sf�et Address: Recelved by:; - y ��" 2750 Kelley Parkway l'11n review fee `�t,�x�sHo��.� Orono,MN 55356 = _ : _ Total Fee - - Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (P/ease print) GENERAL INFORMATION: ,/� � JobSiteAddress: .3 '.�'��5 l /•VlhCi'��h /"7�/-� Will this be a Parade of Homes, Remodelers Sho case Home or other Display Home1 Yes No 1I yes,a special event permlt!s requlred wlth Pollce Department and C!ty CouncH approval 60 days prlor to fhe event. Shudle bus service wlll De requlred uniess app/lcant demonstrates suff'�cient on-site parkJng!s avaHa6le. Non permltted events wfll not be ailowed. CONTRACTOR/APPUCANT INFORM ION: Name: �G�/1.+¢.1'�2 V'O S , LlilYh C.•O State License# (p Expiration Date: � /(o Lead Certification Number: � ••�,(�30�—/ Expiration Date: g�i�"�/S (for work on homes that were construcfed prlor to 1978 Phone: (cell) (office) -a,77— Ma(ling Address: / aY V City: h ZIP: j" Contact Person: p i� Applicant is: ontrac o / Homeowner �cir�ie o�.� Email and/or Fax: C ' y� ,,�, SC.V� .�t.P' Hd PROPERTY OWNER INFORMATION: Name: }� G�,� �Gt S Phone(day): � , �,. ` Address: ��S�.S I V!�4S'�Oh nV� City: �YOH O, �1�ZIP: ,��9/ Email and/or Fax: PROJECT INFORMATION: Overall ro'ect descri tion: �a�=� �sl Gl� G��o� - Type 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 Dist�ict(MCWD) � 18202 AAinnetonka Bivd ❑Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roaf,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora Estimated Construction Valuation of Project(excluding land) $ • � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide ail inforrriation required or requested by the Building Department; • Ce�tifies that the informatfon supplied is tn�e and correct to the best of hfs/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 altemative but to reject it untfl it is complete; • Some or all of the informatlon that you are asked to provide on this epplication is classified by State law as either private or confidential. Private data is informaUon which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to e(ther the public or the subject of the data. Our pwpose and intended use of this inforrnation is to annually update our records and records of other govemmental ayencies required by law. If ou refuse to su I th infortnation the lication me not be fssued. Applicant's Signature: Date: 3 ��' Owner's Signature: Date: Last Updated:January 2015