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'F. <br /> City of Orono <br /> � <br /> • Building Permit Application for Maintenance / Renovation � <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> ��,0,�.� PO Box 66 ? <br /> Crystal Bay, MN 55323-0066 Date received: ,;r;p <br /> �,a � �-,��� s, Street Address: Received by: <br /> �',�,t � �� 2750 Kelley Parkway Plan review fee: <br /> �kE5H04� Orono, MN 55356 ;M <br /> Total Fee: s:;, <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 4� <br /> ,� <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: j� w <br /> Job Site Address: _ _�'�� � - �/7'� J-J� ' � <br /> � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No � <br /> If yes, a special event permit is required wifh Police Department and City Counci!approval 60 days prior to the event. Shuttle bus service wil(be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> '�� <br /> CONTRACTOR/APPLICANT INFORMATION: ° <br /> Name: ! . �', S l���'l�} �o �.5� �� <br /> State License# '��� <br /> :S�,3oy�' Expiration Date: ZQ�� ;� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were construcfed prior to 1978 'a� <br /> Phone: �- �Y 7� - �-53 (office) (o� �- � E 7 3 / r � (cell) '': <br /> Mailing Address: v, �N�' <br /> G�S:, S- �, Sr�,ti��c �--1� D� City: f'1`l,�rv�..c�',s 2 ZIP: 5'S�GL,�- :7 <br /> Contact Person: licant is: �ntrac�or� Homeowner F� <br /> �-�j� App � (Circle One) <br /> Email and/or Fax: '"`� <br /> PROPERTY OWNER INFORMATION: � <br /> Name: 2, L1, � r—�. S (��a D F IL.,, �''' <br /> Phone (day): <br /> Address � City: ZIP: � <br /> Email and/or Fax '�; <br /> ;� <br /> PROJECT INFORMATION: <br /> T e of Pro'ect: �- <br /> YP 1 Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) n <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ��+, <br /> ❑ Re-roof, cedar ❑ Restorafion ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-Q590 <br /> �Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ��h F�l-t ❑W indow(s) <br /> www.minnehahacreek.orq <br /> :�a <br /> �. <br /> Overall Project Description: �t y-� p --- �- --S G�,� �� <br /> Estimated Construction Valuation of Project(excluding land) $ �j c���� � 'F`�� <br /> �� <br /> `;� <br /> APPLICANT ACKNOWLEDGEMENT: >� <br /> Agrees to provide all informafion 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 <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 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 �r <br /> data. Confidenfial 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 infor ation is to annually update our records and records of other govemmental agencies `� <br /> re uired b faw. If ou refu to su I t e inf ation,the a lication ma not be issued. ;"� <br /> � � ��� <br /> � � � -� <br /> ApplicanYs Signature: Date: <br /> Last Updated: 08-09-2011 ';`� <br />