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` � � City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRU AL EXPANSION) <br /> �O�O Mailing Address: R Permit number: ��(�—D�3� <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 OC-� 2�p�received: 2 ��� <br /> Street Address: RReceiyed by: <br /> y G� 2750 Kelley Parkway C�-r(OF F'1�N eview fee: <br /> � <br /> t � Orono, MN 55356 <br /> '�KEst�o� � ��� , l/l/ <br /> -�.._ Total Fee: <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 must be ubmitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: / � v� L b !1 L. A � � I�/' <br /> Job Site Address: [ <br /> Will this be a Parade of Homes, Remodelers Show ase Home or other Display Home? ❑ Yes ❑ No <br /> lf yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle 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 INFORMATION: <br /> i�lame: <br /> State License # Pella Northland Expiration Date: <br /> Lead Certification Numk 15300 25th Ave N. Ste 100 Expiration Date: <br /> (for work on homes tl Plytnouth, MN 55447 <br /> Phone: (ce L�c # BCC45090 Ph. 763%745-1400 (office) <br /> Mailing Address: ZIP: <br /> Contact Person: �� g 5 � � ys , L b y 7 Applican is: Contractor omeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER IN�FQ RMATION: <br /> Name: K Q C� � l �a � l /1 �e l <br /> Phone (day): (, ( 7 3� S''• � � 3 ' <br /> Address: � .s �/b a � ry Q �,� ���� City: �en� �6 �,t ZIP: �S 'S'S� � <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> T pe of Project: Any earth movement may also require <br /> Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Re-roof, as halt �Re air Minnehaha Creek Watershed District(MCWD) <br /> p p ❑ Storm Damage 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 /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ �J O <br /> � <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 I the information, t ication ma not be issued. <br /> ApplicanYs Signature C--� Date: � b � � � ` <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />