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p� . R� � .. . �_ � � .x,��" - # ��#�� `�t,,�° f'S`' � . .�., . � ��yf�� % � �,^'�! �� .s�'dw-� City of Orono � ��,t � �'�� '�L �� � - . Building Permit Application for Maintenance / Renovation -:��k�.�� ' �� �>;' • (windows, doors, siding, re-roof, etc.) � Mailing Address: � �' �,0,�. PO Box 66 Permit number: � O Q Crystal Bay, MN 55323-0066 Date received: ,� �� ., �a �t� ,� 3 � �, � Street Address: ' Received by: �',�c,t t �"� �ti 2750 Kelley Parkway Plan review fee: �kESH�4� Orono, MN 55356 _� Total Fee: ��:' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �°x; 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: _' _% �d�j�/„�� ,��..' � l��= , � � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �-IQo _�'�' If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be �` required unfess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ..4� CONTRACTOR/APPLICANT INFORMATION: �,. „��I Name: ��/�2 ��/�'JS ��UG�"� �� /f.o%=1��-iiU ��iti - State License# � ,��, �� .��'-� xpiration Date: 3/�3 jjl�, i �'' Lead Certification Number: �� Expiration Date: T� ` � (for work on homes that were constructed prior to 1978 �a Phone: ��.� �� q „��'U� (office) (cell) �:� Mailing Address: City: ZIP: L� � Contact Person: Applicant is: Contractor / Homeowner (Cirde One) N, �:� Email and/or Fax: k PROPERTY OWNER INFORMAT ON: � 4"� Name: � �— �:,^ ��i��f� . � /j/�- � �� /= "� �� Phone (day): � ? Address: J ,/�' h �� /yj �� City: �iq o �j� ZIP: yj�� �� / 6��/ lJ l,/Pi- � �� Email and/or Fax T � ' °�T �°� ,:�:; ��. �:;� �� PROJECT INFORMATION: ' Type of Project: Any earth movement may require � ' � ❑ Door s MCWD review&permits: ;� Y 3, O ❑ Remodel ❑ Fire Damage � Minnehaha Creek Watershed District(MCWD) :�� ; � [� Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd � �F< ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �� Phone: 952-471-0590 y ❑ Re-roof,other(spec�fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 � �„ www.minnehahacreek.orq ❑Window(s) ,� #�'; Overall Project Description: � Estimated Construction Valuation of Project(excluding land) $ % , v Q � , �� �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 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 ="' `' purpose and intended use of this information is to annually update our records and records of other governmental agencies � r; re uired b law. If ou refuse t su I the information,the a lication ma not be issued. � � � � ApplicanYs Signature: / GQ ' ��-= Date:��l � � � .. Last Updated: 08-09-2011 :-� , �