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, City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-raof, etc. — NO STRUCTURAL EXPANSIONj <br /> ���'' �`� Mailing Address: Permit number: p� �"��d � <br /> ���1 .', PO Box 66 .�I <br /> � '� Crystal Bay, MN 55323-0066 Date received: 7 d ���� <br /> � �� � Street Address: Received by: <br /> `�,\� ��� 2750 Kelley Parkway Plan review fee: <br /> �, tqk���������� Orono, MN 55356 � � <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 submitted.�msq'�/ �} l/`� <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � r`� <br /> Will this be a Parade of Homes, Remodelers Show se Home 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. Shuttle bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORM TIO : , <br /> Name: S� Q, <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constr cted�ior to 1978 <br /> Phone: (cell) 2 (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: _-- - - Applicant is: Contractor / Homeowner (CircleOne) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �QwY�� �".� (j���Q, <br /> Phone (day): ----_..._.._.____.._.____.�. . . <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <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 /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orc7 <br /> Estimated Construction Valuation of Project (excluding land) $ .SDO, 00 <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 1 the information, th ication ma not be issued. <br /> - ....._y � <br /> :A_..,:...__. <br /> Applicant's Signature: Date: <br /> �-'".` <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />