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, . - City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O�O Mailing Address: Permit number: (' <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> � <br /> Street Address: Received by: <br /> � G� 2750 Kelley Parkway Plan review fee: <br /> `� Orono, MN 55356 <br /> �'�kFSNo�`` <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 print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �3�� /l/�,,-J�, ���,,, /J� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,�IVo <br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �� �o ,�,,�,� <br /> State License# ,S— � Expiration Date: � � �f <br /> Lead Certification Number: ����_ -,7� S—�/_ � Expiration Date: / �S� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �Z _ 4 S—_ f^-� (office) <br /> Mailing Address: f,� d �,� k,,,�ti City: � ZIP: SJ":3S'�� <br /> Contact Person: �' I,,ri 5 CJUo�•� Applicant is: ontractor / Homeowner (CircleOne) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �-t��trc (Jt�-�Y <br /> Phone (day): ys-,�- �G�- G2G3 <br /> Address: /3/� /f/��fj, /�.,H,, 1� City:��d ZIP: 5��G !.� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect description: /��1�� N � n�,u !- <br /> Type of Project: A eart movement may als require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: <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 /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> �- Fax: 952-471-0682 <br /> ❑Window(s) �n�� r�� / v www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) $ O • !�v <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 are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> 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 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, the a lication ma not be issued. <br /> ApplicanYs Signature: � Date: 'I " 3'-��� <br /> Owner's Signature: Date: <br /> Last Updated:03/O6/2013 <br />