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�� �� � � ���� <br /> � � City of Orono ��,�-'��� � �Io� �� � <br /> Building Permit Application for Maintenance / Replacement / Renovation � <br /> �` <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) �: <br /> :� <br /> �O�O Mailing Address: Permit number: / � D�D 7� <br /> PO Box 66 ,/ <br /> Crystal Bay, MN 55323-0066 Date received: �! /,j <br /> � <br /> Street Address: Received by: g <br /> ��, G� 2750 Kelley Parkway Plan review fee: ��.��a'� �,; <br /> Orono, MN 55356 �� <br /> �'�KESHo��` 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. �'�' <br /> Incomplete applications will be returned. (Please print) � <br /> GENERAL INFORMATION: , <br /> ;� <br /> Job Site Address: ��� /l�czr�v f C-�rG��- �� <br /> �,.� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Dis pla y 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 serv� will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ' <br /> �'•� <br /> CONTRACTOR/APPLICANT INFORMATI N: <br /> �, 1Q � <br /> Name: ���a r� /V G�ST�..� ;�3 <br /> State License# ---- Expiration Date: — � <br /> Lead Certification Number: '— Expiration Date: — ': <br /> �.< <br /> (for work on homes that were constructed prior to 1978 ' <br /> Phone: cell � <br /> ( ) �l� - 3�.8 --o S 78 (office) ��3- �97-3�Sy �x-� l c>d _� <br /> Mailing Address: r �;rc/� City: ��a,� ZIP: S"5"'3j6 <br /> Contact Person: � Applicant is: Contractor / omeowne (Cirde One) � <br /> Email and/or Fax: <br /> �� <br /> PROPERTY OWNER INFORMATION: <br /> Name: � <br /> �� <br /> Phone (day): �� � � :�, <br /> Address: ' — City: ZIP: �Y" <br /> �: <br /> Email and/or Fax: ;�; <br /> $� <br /> PROJECT INFORMATION: Overall pro�ect description: �f <br /> Type of Project: Any earth movement may also require <br /> MCWD review&permits: � <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage �;,. <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 /> _�, <br /> ❑ Re-roof, other s eci Phone: 952-471-0590 ' <br /> ( p fy) ❑ Siding �'Other: (specify) �, <br /> Fax: 952-471-0682 � <br /> ❑Window(s) ����'� www.minnehahacreek.orq � <br /> Estimated Construction Valuation of Project(excluding land) $ _ ��d � <br /> ';� <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: � <br /> • Agrees to provide all information required or requested by the Building Department; � <br /> `� <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; ti�; <br /> ��S <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, e a ic tion ma not be issued. � <br /> _� <br /> ApplicanYs Signature: — Date: '�:�G/' /� � <br /> �� <br /> "u <br /> Owner's Signature: Date: o-� <br /> Last Updated:03/06/2013 `}`� <br /> �'a <br /> f <br /> _ . . . , ,.. ..: ���z <br />