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{ �� =_� �As City of Orono �� � , � , � �� Building Permit Application for Maintenance / Renovation �� (windows, doors, siding, re-roof, etc. � ) � Mailing Address: Permit number: �U��—� � O�,D,�O PO Box 66 � �� Crystal Bay, MN 55323-0066 Date received: Z / �� � , �� x j �a '� �' s, Sfreet Address: Received by: �: � : '�� �'�,n � �� 2750 Kelley Parkway Plan review fee: �� L'�kEsxo4''� Orono, MN 55356 � -- Total Fee: ' �.;� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ��Q. �� �•f This application form must be completed in full and all required information must be submitted. `� ' ' Incomplete applications will be returned. (Please print) � � ' GENERAL INFORMATION: ��• Job Site Address: �� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No /f yes,a special event permif is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service wi/l be � �� required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ,�� { y �,�, fi�� ,i CONTRACTOR/APPUCANT INFORMATION: 1 � •; Name: P c� � �" � �: State License# Q �C��?� j Expiration Date: � �. Lead Certification Number: �^ Expiration Date: � (for work on homes that were constructed prior to 1978 � Phone: � _ � � -� , (office) ��- �� -� �'� (cell) � Mailing Address: ` City: �, ZIP: �T �� Contact Person: j—�� e� S�f., Applicant is: Contractor / Homeowne� ��irc�e one) � �� J � Email and/or Fax: � � PROPERTY OWNER INFORMATION: : Name: � �T� ," e �t o r � a� �.5� y'� � i Phone (day): �J�"�f�7 Z' O � � � Address: �' ? S S�-��/ �` �_, ' Email and/or Fax � �� —�� City: G � �. /�� ZIP: � � PROJECT INFORMATION: �� Type of Project: Any earth movement may require � ; ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: �� �}.Re-roof, as halt Minnehaha Creek Watershed District(MCWD) � �,3' p ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd � ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 `'� Phone: 952-471-0590 } '�• ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 � � � �:. ��f ❑Window(s) www.minnehahacreek.orq � j �a Overall Project Description: �`� Estimated Construction Valuation of Project(excluding land) $ � � 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 altemative � ::�; but to reject it until it is complete; 2:� � k � � 1 • 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. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our ,*� °-:j purpose and intended use of this information is to annually update our records and records of other governmental agencies �� : �; re uired b law. If ou refuse to su I the inf r ation,t a lication ma not be issued. �,y a� r i ApplicanYs Signature: -- � Date: x�,��j/ �� �_� i Last Updated: 08-09-2011 z . �, • • ; . � - ._3-,.. ��