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r;.� i �3�"`'.a �"r+r�T-�o^� + �'�9 ... �F . . .. ... �� '�d �; � � � C i ty of O ro n o �� :� : Building Permit Application for Maintenance / Replacement / Renovation � � ` (No structural expansion. Only windows, doors, siding, re-roof, etc.) O Mailing Address: Permit number: O l�� ? � �O PO Box 66 �� Crystal Bay, MN 55323-0066 Date received: S� `` ` � ' Received by: � �.' � � StreetAddress: k . ,�-,., yF G� 2750 Kelley Parkway Plan review fee: fr� �, Orono, MN 55356 � `�'�ESH�� Total Fee: ��/��, � ;� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us `C � This application form must be completed in full and all required information must be submitted. - Incomplete applications will be returned. (Please print) ' � GENERAL INFORMATION: V �.. Job Site Address: j� �c> L�/{'�I� �1�� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No ": 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 required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: `� � f'��1 Name: �7 �.�, ��•� v _ d State License# �� ' Expiration Date: 3 - 3 � -1�� '';;;,; Lead Certification Number: Expiration Date: 4,� (for work on homes that were consfruc ed prior fo 1978 �� Phone: (cell) (.e f - �I� - � 3 3 S (office) Mailing Address: v ry� �f ��,,;..� City: � � ��z ZIP: S� �z / � Contact Person: �',��,� � Applicant is: ontract r / Homeowner (Circle One) �: Email and/or Fax: �TO�M y ��,�S�Y��QH2 cJ� �'U�� PROPERTY OWNER INFQRMATION: Name: ,��(il �j f u e S Z 1: Phone (day): (�(� � �S/ � �� (e o `�': Address: `/ � L�� ve— City: C�/��irU ZIP: S�� l �,� � Email and/or Fax: PROJECT INFORMATION: Overall pro�ect description: �' Type of Project: Any earth movement may also require � ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: ` � Minnehaha Creek Watershed District(MCWD) f�:, �e-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd � ' ' ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 =,m ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 � Fax: 952-471-0682 N ❑Window(s) www.minnehahacreek.orq `�� -# Estimated Construction Valuation of Project(excluding land) $ S� . �J � �� APPLICANT ACKNOWLEDGEMENT: � • Agrees to provide all information required or requested by the Building Department; � �� Certifies that the information supplied is true and correct to the best of hislher knowledge. The applicant recognizes that they are k�� • solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to `�� reject it until it is complete; � � ;. .� • Some or all of the information that you are asked to provide on this application is classified by State law as either private or `'-�:`.{ confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. I Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and .�..� intended use of this information is to annually update our records and records of other govemmental agencies required by law. If � �,� ou refuse to su I the information,the a lication ma not be issued. � ��, -�-�:�-� ,----- . �. �`� ApplicanYs Signature: Date: � `i ,; Owner's Signature: Date: LL�. ��_+ `° i Last Updated: 03/06/2013 , � �, �. �:"� . ._ . ;