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� City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) �OA r Mailing Address: Permit number: ^v Z �VO PO Box 66 _ Crystal Bay, MN 55323-0066 Date received: � �. a Street Address: Received by: :- � 2750 Kelley Parkway Plan review fee: `�t " Orono, MN 55356 �kFst,�� /SD 7� Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 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: � � �/� f� � � �� 1� � 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 City Council approval 60 days prior to the event. Shuttle bus rvice will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowe . CONTRACTOR/APPLICAI�T INFORMATION: Name: � � State License# �� , ', Expiration Date: Lead Certification Number: Expiration Date: ' (for work on homes that were constructed prior to 1978 Phone: (cell) (office) �� —�� Mailing Address: ; � Cit : � r � � Contact Person: Applicant is Contractor / omeowner (Circle One) Email and/or Fax: �;� � � � _ � PROPERTY OWNER�NFORMATION: ( Name: �.(,�1�� j' Phone (day): � � Address: � � City: ZIP: �,5 3 Email and/or Fax: PROJECT INFORMATION: Overall project description: � - � '�' � ? � r��`i Type of Project: Any arth movement may also require ❑ 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.minn hahacreek.or Estimated Construction Valuation of Project(excluding land) $ 'J � 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 law as either private or confidential. Private��is information which generally cannot be given to the public but can be given to the subject of the data. Confidential da is,rt�for ation which generally cannot be given to either the public or the subject of the data. Our purpose and intended use f s inf matio is to annually update our records and records of other governmental agencies required by law. If ou refuse t s inf , e app i ma not be issued. ApplicanYs Sign � . Date: 1�/ �i � " � � Owner's Signature: Date: Last Updated:03/06/2013