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' Cit of Orono ���9 � <br /> Y <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mai(ingAddress: Permitnumbec �p/ — <br /> �,0,� PO Box 66 <br /> 0 �, � <br /> Crystal Bay, MN 55323-0066 Date received: ��.30 � <br /> � �`3 k'�''�r Received by: S <br /> �,� ��� �, StreetAddress: <br /> �,�c, „„q,, �titi 2750 Kelley Parkway Plan review fee: �, SJ <br /> t�kESH�04`� 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. <br /> Incomplete applications will be returned. (Please prrnt) <br /> GENERAL INFORMATION: /� �I I/ / / <br /> Job Site Address: �:� � � �.l l.� �i � T(�1� �� � T��� G, [GC �'��S �-Gt d7 C �✓v� Q <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Disptay Home? ❑ Yes ..�No <br /> If yes,a special event permit is required with Police Department and City Counci!approval 60 days prior to the event. Shuttle bus servic�will be <br /> required un/ess applicant demonstrates sufficient on-site parking is avai(able. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ��� � ����� <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) (cell) <br /> Maifing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFO MATIO : <br /> Name: Cc VU� -� <br /> Phone (day): � (� �- ��/�� ._ '�G s � <br /> Address: G �(j !� Tl� r4 ��q�i.�L� atr�l�� �A c�ty: (Jr�� p ZIP: S.S!'S.E . <br /> Email and/or Fax �S��y�y o, p-t-S-�rd, C d v� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) Remodel ❑ Fire Damage MCWD'review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphatt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) v✓ww.minnehahacreek.orq <br /> Overall Project Description: C UVI U�� �� v� � (;c n <br /> (;L Y c:t 2 �-�-� <br /> Estimated Construction Valuation of Project(excluding and) $ ��� � -���, p� <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this appfication is classified by State law as either private or <br /> confidenfial. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou ref o s the ' formation,the a lication ma not be issued. <br /> `_--- ---- i <br /> Applicant's Signature: � - Date: � -3� - � � <br /> Last Updated: OS-09-2011 <br />