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' ` ,� City of Orono <br /> � Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O ` _O Mailing Address: , <br /> C. <br /> IY Po BoX ss <br /> Permit number. �!5 '� <br /> Crystal Bay, MN 55323-0066 Date received: �� ' � <br /> � <br /> Street Address: Received by: � <br /> 9 G�` 2750 Kelley Parkway PI review fee: �� ' L�k <br /> `� Orono, MN 55356 � � <br /> lqkESH��� Tota�F�e�' � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � <br /> This application form must be completed in full and all required information m st be subm,ittey� � <br /> Incomplete applications will be returned. (Please print)-���}����/�'� <br /> GENERAL INFORMATION: 'L <br /> Job Site Address: �f 9� 1 o✓n� �,-y ,� �,, <br /> Will this be a Parade of Homes, Remodelers Showcase Ho em or other Display Home? ❑ Yes ❑ No <br /> If yes, a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATIO <br /> Name: � � -� ,.�J <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were constructed prior to 1978 <br /> Phone: (cell) �Z- �5�— S'`-/ �- (office) <br /> Mailing Address: 6 - City: ZIP: � <br /> Contact Person: �`�,�� �� � �- Applicant is: Contractor / omeowne �c���ie o�e> <br /> Email and/or Fax: � ��, � � � ,Q , �,�.� _ �l � ' � <br /> ��',--�-�Te.�—� <br /> PROPERTY OWNE INFORMATION: <br /> Name: ��_ �.��� � c�G�--`� �� <br /> Phone (day): z — �f�_ ,� S^�L� <br /> Address: � —� �' � <br /> / l 9'h L o o, �,vt�� city: �/� zIP: S^S�'�,6 `7 <br /> Email and/or Fax: ���f�� 1� � ��G _... ,,y, �< �-� i a .� <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> Re-roof, other(specify) ❑ Siding �Other: (specify) Phone: 952-471-0590 <br /> ��t � ��O � Window s Fax: 952-471-0�82 <br /> ��❑ ( ) www.minneh reek.or <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> ��� � c�, � <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 governmental agencies required by law. If <br /> ou refuse to su the fo ti ,t li e ' <br /> ApplicanYs Signature: Date: �- �� 6 <br /> Owner's Signature: Date: �0 p�-O 1,� <br /> Last Updated:January 2015 <br />