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City of Orono Building Permit Appiication for Maintenance / Replacement / Renovation - (No structural expansion. Only windows, doors, siding, re-roof, etc.) � � Mailing Address: Permft number: 6/ Q d 5 ` :��N��`�°, PoeoXss � i� � � Crystal Bay,MN 55323-006 Date received: - — � i �., �� . Street Address: ` Receiv��I by;__ ; ��, 2750 Kelley Parkway aI Plan review fee;` �.,41�,� �`��`;` Orono,MN 55356 J "" a 01 � d D � - T � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � This application form must be completed in fuii and all required information must be submitted. � Incomplete applications will be retumed. (Please print) �' GENERAL INFORMATION: � � Job Site Address: 3 'y� � �� WIII this be a Parade of Homes,Remodelers Showcase Hane or other Display Home? Yes Plo ff yes,a specia!everrt permit is required wlth Pofice Department and City Councll approva!60 days pNa to the evenf. ShuKle bus wil!be required urtless applrcani demonstrates suffrcieM onsite parking is availabfe. Non-permitted events wlfi not be aUowed. CONTRACTOR/APPLICANT INFORMATION: Name: C.C��I �Yt`�.�.5 ��t�j � ��'LJ D��Z/sL� State License# f3Ci 3� SS'SS' Expiration Date: � 3 � Lead Certification Number: ^/f,¢ Expiration Date: (fer work on homes that were constructed prlor to i978 Phone: (cell) 952—7 lo-3'78'3 C�� (office) 9'�2—g� —�'+{! Mailing Address: O('Z, � Cit :/Lir/Z1Ltr�/¢-ZIP: S3'Y Contact Person: � �- � Applicant is: Contracto ! Homeowner �ci.�b o�� Email and/or Fax: /1��/�y�.t�x•�1JQ L��t^�3 2,� $�y PROPERTY OWNER INFORMATION: Name: �� 'r�'��' ',.��' � P��ZZ�.. Phone(day): .2�. Q.- ��G�r.c-� Address: �L� / dT2T2� L�'LL` C�Y� B+�tJ'F� ZIP: ��3�� Email and/or Fax: ��q��1�� ',�l.TIBl2+tIL'T' NET PROJECT INFORMATION: Overall ro'ect escri tion:/1�OJV—S�V�R� �7 C� !/G/pl�6cf3�4�vT'� Type of Project: �p� My earth movement may also require ❑Door(s) �Remodel l�❑Fire Damage MCWD review 8 permits: ❑Re-roof,asphalt ❑Repair /� ❑Storm Damage Minnehaha Creek Watershed Dfstrict(MCWD) ❑Re-roof,cedar ❑Restoration 18202 Minnetonka Blvd ❑Water Damage Deephaven,MIV 55391 ❑Re-roof,other(specHy) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora Estimated Construction Valuation of Project(excluding land) $ APPUCANT ACKNOWLEDGEMENT: • Agrees to provide all information required o►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 apptication being aware that upon failure to do so,the staff has no altemative but to reject it until it is complete; • Some w alt of the infoRnation that you are asked to provide on this application is classified by State Iaw 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 lnformation 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 govemmental agencies required by law. If ou refuse to su the i orma' a lication ma not be issued. ApplicanYs Signature: Date: _� � � � � � . Owner's Signature: Date: