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� � ,� �,i � � ��: C�ty of Orono , ` ` Building Permit Application for Maintenance / Replacement / Renovation � j, (No structura l expansion. On ly win dows, doors, si ding, re-roo f, e tc.) �< " Mailing Address: �'"` ��N PO Box 66 Permit number: 070/,�— /D 3 Z' �':; � Crystal Bay, MN 55323-0066 Date received: !D -/ -/ �.� Street Address: Received by: ; uy �F � 2750 Kelley Parkway Plan review fee: � L Orono, MN 55356 ' ; `�kFSHo�� /D S Z S �� Total Fee: � Main: 952-249-4600 Fax: 9 5 2-2 4 9-4 61 6 www.ci.orono.mn.us ,,;; �y� This application form must be completed in full and all required information must be submitted. �° E��Y Incomplete applications will be returned. (Please print) GENERAL INFORMATION: 33 Z� NCc-UQJ�-�- l�� Job Site Address: 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 Ciry 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: �" � Name: � �; State License# Expiration Date: i �,; �`a �� Lead Certification Number: Expiration Date: �, y (for work on homes that were constructed prior to 1978 �`' ��'� �� �;� Phone: (cell) (office) �; �,�' Mailing Address: City: ZIP: � Contact Person: Applicant is: Contractor / Homeowner (Circle One) .; �: �;: Email and/or Fax: ,,_' ��` �r' � PROPERTY OWNER INFORMATION: � �,:� Name: �C3Y`� � D{1iV�.0 OY\J Phone(day): �r 2 - � �D — D70 � �.; Address: 3�-Z({ ��(��Q �_ City: ZIP: �j�j 3� � ,:: Email and/or Fax: � �,,�: PROJECT INFORMATION: Overall pro�ect description: f � Type of Project: Any earth movement may also require r� �,' ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: �' � Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) " 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 ' Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ aDD. DD r;; �� 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 his/her knowledge. The applicant recognizes that they are `: ' 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 taw as either private or RFti �y,; confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. ;4 �� Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and � E intended use of this information is to annually update our records and records of other governmental agencies required by law. If �: ��;� ou refuse to su I the information,the a lication ma not be issued. k'.�{ Applicant's Signature: ,�c i xs�`-8j2.P ,ro,�� Gv�P�c.� Date: �� -�'" l� fir ��` Owner's Signature: Date: �s: Last Updated:03/06/2013