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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) ��T Mailing Address: l VO PO Box 66 Permit number: Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: y�, G� 2750 Kelley Parkway P�an review fee: 1qkESHO�� 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: �-s �v rn�( ��.,��Q Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No If yes,a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus s ice will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/A�PnLICANT INFORMATION:n Name: V�,� 1 . S 11�,� � �I--�� l '�i�S� State License# S-�,� �.i Expiration Date: � - / �; Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) �/� --��,7_ 3 � � (office) Mailing Address: L S � s S� S/a��.-v r,��<� �-K� U� City:Y1-,; ,�ti� ��,C ,� ZIP: SS�G �� Contact Person: Applicant is: Contractor / Homeowner (C i r c l e O n e) Email and/or Fax: _ �U�q rz��.prn r� ,�; � /�o L C_;;.;n� PROPERTY OWNER INFORMATION: Name: �;�I L K ��v r �-v Phone (day): �S� _ Y � a _ y y 7 � Address City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall project description: R��°"t �� c S-�.�,ti.�J, <'`,.' G�a,�y C� c-" Type of Project: Any earth move t may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: �Re-roof, asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) ❑ Re-roof,cedar 15320 Minnetonka Blvd ❑ Restoration ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 ❑Window s Fax: 952-471-0682 � ) www.minnehahacreek.orq Estimated Construction Valuation of Project (excluding land) $ � 0 0 � 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 governme`tal agencies required by law. If ou refuse to su I th info aY n,t a lication ma not be issued. ApplicanYs Signature: Date: � � �S Owner's Signature: Date: Last Updated:January 2015