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::�. ;� < � City of Orono � � �� .. '}t"'"... 7�, ' Building Permit Application for Maintenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: � — t O�,�,�.0 PO Box 66 ; Crystal Bay, MN 55323-0066 Date received: � ',a � "�'.;� s, Streef Address: Received by: � ��c,t '� �ti 2750 Kelley Parkway Plan review fee: ' 9kESH�� Orono, MN 55356 � � � Total Fee: �� Q��. �� ,- 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: ��7/t- L,��✓D�1 /t� u„�Q S'S��f � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No �'� If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus s rvi e wil(be ;� r�quired unless applicant demonstrafes su�cier,t or,-site parking is available. �!�n-permitted events will not be a!lowed. CONTRACTOR/APPLICANT INFORMATION: c� Name: �(t', sr�0 S Sz- l��L� �, iJ-�,S `` State License# Expiration Date: � Lead Certification Number: Expiration Date: ``� (for work on homes that were constructed prior to 1978 Phone: (office) (cell) Mailing Address: City: ZIP: Contact Person: Applicant is: Contractor / Homeowner (Circle One) T 4� Email and/or Fax: PROPERTY OWNER INFORMATION: <� Name: /„�, fiL..�-.� .J . ��G- �-G�.�t',p :�`: Phone (day): C�S Z t��L S�S� Address: %j/� �o M� L. No� � �/ c�ty: /Gj� ��✓D ziP: �SS 3 6�/ Email and/or Fax �. �, � 3 f4�L y/�,lr0 C✓ /'� �,SlSZ , G o�"� p PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: '�$ Minnehaha Creek Watershed District(MCWD) �Re-roof, asphalt ❑ Reoair f_l Storm Damage 18202 Mlinnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 w:� ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 `�� ❑Window(s) www.minnehahacreek.orq '�� Overall Project Description: �� !N:a Estimated Construction Valuation of Project(excluding land) $ �f,SO�j <,.`e :,:� 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. 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 information,t e lic tion ma not be issued. :;<: ApplicanYs Signature: / � Date: o�� 7, �'$�/ � ,i Last Updated: 08-09-2011 '"� ��'�