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<br /> � ' City of Orono �
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
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<br /> �O�O Mailing Address: Permit number:
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 }' Date received:
<br />� Street Address: Received by:
<br /> y� ` 2750 Kelley Parkway �`` � Plan review fee:
<br /> i t �,�' Orono, MN 55356
<br />�;._ �KBSHOS�
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us °
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<br /> This application form must be completed in full and all required information must be submitted. �-;
<br />�;: Incomplete applications wilt be returned. (Please print)
<br />`' GENERAL INFORMATION: ,- . -
<br /> Job Site Address: r � ��7 ���vi;,� �� �(i- �'� ���, � ; �'�—v 1,t ^ ,� 1�� �..� � ��
<br /> Will this be a Parade of Homesx Remodelers Sh wcase Home or other Display Home? ❑ Yes �No
<br />� If 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.
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<br /> CONTRACTOR/APP ICANT INFORIU�ATION:
<br /> L���, ° +� �
<br /> Name: ;, �S, t�� �C_��� � �
<br /> State License# Expiration Date:
<br /> y�. Lead Certification Number: Expiration Date:
<br /> t� (for work on homes that were constructed prior to 1978 � �
<br /> ,; ` Phone: (cell) ,;/ Z "�� �; c:, l (office) �s
<br /> Mailing Address: ,,- /�:�1 City: ; r ��-r-,�-- ZIP: � �— 3 � �
<br />�`� Contact Person: ,,�, Applicant is: Contractor / - omeowner� �c���ie o�e> �
<br /> Email and/or Fax: ���c�_ ' „��' C�r---�
<br /> E;�
<br /> : PROPERTY OWNER IN��MA,-T`ION: �
<br /> v., Name: � , N�,� n��,
<br /> ,. Phone (day): ,�/L .�'o/ S� d � �
<br /> Address: ��-T,� _;�.,,,�,1 �.� ��� ,/of City: 0�� ,,� � ZIP: � � T�—�
<br /> Email and/or Fax:
<br />�;.:;
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: Any earth movement may also require
<br /> e.
<br /> ` ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits:
<br />�e., Minnehaha Creek Watershed District(MCWD) �
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage „
<br /> 18202 Minnetonka Blvd
<br />� ;: ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br />�° ❑ Re-roof, other(specify) [�iding ❑ Other: (specify) Phone: 952-471-0590
<br />�: Fax: 952-471-0682
<br /> s. , ❑Window(s) www.minnehahacreek.org
<br />�` Estimated Construction Valuation of Project(excluding land) $�r,� f�
<br /> APPLICANT ACKNOWLEDGEMENT:
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<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 altemative but to ��•
<br /> _ reject it until it is complete; �
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<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 govemmental agencies required by law. If
<br />'��:`` ou refuse to su I the information,the a lication ma not be issued.
<br />` i ApplicanYs Signature: � Date: �
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<br />�. ' Owner's Signature: � ����" Date: ,' �i ?/ / ?
<br />�` Last Updated:03/06/2013
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