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J City of Orono Building Permit Application for Maintenance J Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) Mailing Address: � �ON��,, Po soX ss Pe►mft number: B I D D 5 Crystal Bay, MN 55323-006 Date received: � - �-� i �� Streef Address: ` Received by: , �. 2750 Kelley Parkway �{I Plan review fee: ` � J . �.�A.��ii�� . " Orono,MN 55356 p"�01�� d� 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) c� � GENERAL INFORMATION: 'I D � Job Site Address: 3 y� � �� WIII this be a Parade of Homes,Remodelers Showcase Home or other Dlsplay Home? Yes No lf yes,a special event permit is required with Police Deparlment and City Councll approvaf 60 days prta to the event. ShuKle bus s wil!be required unless applicant demonsirates s�cient on-site parlcing is available. Non�ermitted events will nof be allowed. CONTRACTOR!APPLtCANT INFORMATION: Name: Lt��1 Cfl3"tt..a2S �it33 � ��7'L1030E2/if.l� State License# f��'i 3 2 S-S-SS Expiration Date: -3 � � Lead Certification Number: ��,�. Expiration Date: (fur work on homes that were constructed pNor to i978 Phone: (ceN) 9j'2."'7 `3�7$"�J (p,�e�ar (office) 9'�2—��it —�'""!! Mailing Address: O�Z G, Cit :�r I��P: S3� Contact Person: � �- ��1 Applicant is: ontracto / Homeowner �ci�ie o�� Email and/or Fax: �� ,N Lr� PROPERTY OWNER INFORMATION: Name: _��'t� 'r'G�!'/L!�- $� Pfi��TLL.. Phone(day): Z,.- t;.- r� �`� Address: �( ri., G�.y�- City 8,,,��p ZIP rj�36 [�l Email and/or Fax: ��Q�1�s�� a�tTll2hl�'T' NET' PROJECT INFORMATION: OveraN ro'ect escri tion:/Il07iI-a7�uGTtJ?JSZ- C:B��T G. !/Lt/ol��r,t3+4�l�Tj' Type of Project: �-�,p My earth movement may also require ❑Door(s) Remodel V, MCWD review&permits: � ❑Fire Damage ❑Re-roof,asphalt ❑Repair /� ❑Storm Damage Minnehaha Creek Watershed District(MCWD) ❑Re-roof,cedar 18202 Minnetonka Blvd ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.or4 Estimated Construction Valuation of Project(excluding land) $ APPLtCANT 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 knawledge. 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 w al{ of the informaUon that you are asked to provide on this appflcation 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�se of this information is to annually update our records and records of other governmental agencies required by law. If ou refuse to su the i orma' a iption ma not be issued. Applicant's Signature: Date: r Owner's Signature: _ ' �i_ Date: �J 7i