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� r." y�� ��,� `` �$�p City of Orono �� a �� :: ��.°: � Building Permit Application for Maintenance / Renovation fr� a�� (windows, doors, siding, re-roof, etc.) Mailing Address: �� �,0,�. PO Box 66 Permit number. �. Crystal Bay, MN 55323-0066 Date received: �„ � � � � ��:i � r� Received b I a �:�;.� s, Street Address: y� � ��c, "�� ti 2750 Kelley Parkway Plan review fee: � L�'kESHo4� 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. (Please print) � GENERAL INFORMATION: Job Site Address: �� f rivn/;G; (�;�C �U-�: ;� Will this be a Parade of Hor�es, Remodelers howcase Home or other Disptay Home? ❑ Yes ❑ No ;�� If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service wil!be required unfess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: � Name: ��`�.�(e-7��1f'�� G�� State License# ap� a�� Expiration Date: �� Lead Certification Number: Expiration Date: �� (for work on homes that were construcfed prior to 1978 i� Phone: �fZ � G �' (office) 6�� , 7�� ' �� (cell) � Mailing Address ^0 '� �� ' , � City: .� .� o � � ZIP: �� , '� Contact Person: �_�1��p� �� Applicant is: Contractor / Homeowner (Circle One) � _�s�, Email and/or Fax: ,�� PROPERTY OWNER FO�RMATION: � Name: � l � Phone (day): �5 , _ y7Z � �JR6� ; Address: ��'��i )r,/v;c: � ;�1`,o1a AVE. city: r�c r.<� ZIP: �5��_ � Email and/or Fax ' °°�� r� � PROJECT INFORMATION: •� Type of Project: Any earth movement may require � MCWD review&permits: `-� ❑ Door(s) ❑ Remodel ❑ Fire Damage �� Minnehaha Creek Watershed District(MCWD) >+7 �f Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd :;� ❑ Re-roof, cedar ❑ Restorafion ❑Water Damage Deephaven, MN 55391 :�� Phone: 952-471-0590 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Overall Project Description: ;;:,� Estimated Construction Valuation of Project(excluding land) $ �� :� � � APPLICANT ACKNOWLEDGEMENT: t� • 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 submitfing 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. Confidential 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 � re uired b law. If ou refuse to su I the information e a c3f a not be issued. � Applicant's Signature: � � �� ,.- %' �.�� Date: �'� � � � Last Updated: 08-09-2011 ;� ;��