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. . > <br /> ' � ' City of 4rono . <br /> Building Permit Application for Maintenance 1 Replacement / Renovati�n <br /> (No structural expansion. Only w,indows, doors, ';siding, re-roof, etc.}; <br /> ��r Mailing Address: Permit number. �� /_� ' ��`i2/ <br /> PO Box 66 <br /> � �v� Crystal Bay, MN 55323-0086 Date received: ^'";�" /_'� <br /> � � �� � <br /> Street Address: Received by: ,'�—�. ' <br /> s �'' 2750 Kelley Parkway plan review fee: <br /> `� L Orono, MN 55356 <br /> l�k�s���� 'T'otal Fee: <br /> Main: 952-249-4640 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. ' <br /> tncomplete applications will be returri'ed. {Please pnnt) ' <br /> GENERAL INFOF2MA710N: <br /> Job SitE Address: i � (,,(,C.�L t V1 e-' �fG� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home o otHer Display Home? Yes �No <br /> !f yes,a specia!event permit is requlred with Police Qepartment and Cify Counci!approva!60 days prror to the event. Shuttfe bus service wi!!be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitfed events wi!!not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: q ' <br /> Name: !1. �Y, S, 1..1�YVL�2-{� <br /> State License# �j Expiration Date: .� j ��� <br /> Lead Certification Nurt�ber: ' Expiration Date: <br /> {for work on homes:that were consfnr i�ed prror to 1978 <br /> Phone: (cell) (office) ., f(p j� <br /> Mailing Address: 1 ; �� =- CQ S i d!� u Gity: ', ZIP: 5' 3 <br /> Contact Person: j✓f,$�a � Applicant i � ',Contra tor ! Homeowner (Cl�rcle One) <br /> Email and/or Fax: Cd,!✓1 fi�,y�dY� L 5�,��,(�g �ayy� <br /> PROPERTY OWNER INFORMATlON: <br /> Name: �� p� �� <br /> Phane(day}: r� (p;. <br /> Address: � � � City: �y'OHO ZIP: ��j;?jj� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <br /> Type of Project: � Any earth movement may also re�uire <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Bivd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(speclry) ❑Siding , ❑Other. (specify) Fax: 952-471-0682 <br /> indow(s) ' www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excludingjland) $ ' �v'7 4 , <br /> APPLICANT ACKNOWLEDGEMENT: ' <br /> • Agrees to'provide'all information required or requested by the Building Qepartment; ', <br /> • Certifies thaf fhe information supplied is true and correct to the best of hislher knowledge. The applicant recognizes that they are <br /> solely responsiblej;for submitting a complefe application being aware that iupon failure to do so, the staff has no alternative but to <br /> reject it untii it is complete; , ' <br /> • Some or all of the informatian that you are asked to provide on this application is'classified by State law as eifhe� private or <br /> confidential. Private data is information which generally cannot be given fo the public buf can be given to the subject:of the data. <br /> Confidentiai dafa is'information which generally cannot be given to either!the public or the subject of the data. Our p;urpose and <br /> intended use of this information is fo annually update our records and records of:other governmentai agencies requiretl by law. If <br /> ou refuse to su 1 the information;the a lication ma not be issued. <br /> Applicant's Signature: Date: ��� <br /> Owner's Signature: Date: ' <br /> Last Updated:03/06/2013 <br /> ; <br /> , <br /> i <br />