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'f; t a'-:�ve ,� � City of Orono � � � � a� 4 � . Building Permit Application for Maintenance / Renovation . - ��; - (windows, doors, siding, re-roof, etc.) e=� O Mai��PO Bo�r66 � Permit number: � y_ � Crystal Bay, MN 55323-0066 Date received: �.. o �. o �l � a ��` .��, �, StreetAddress: Received by: ;� �',�, t �"� �ti 2750 Kelley Parkway Plan review fee: ,� l9kESH�g,'�' Orono, MN 55356 �. — 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. }a Incomplete applications will be returned. (Ple se print) '� �=a GENERAL INFORMATION: ��- �� ,� � Job Site Address: r`�( , Jl�� � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No �; j' 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 unless applicant demonstrates sufficient on-sife parking is available. Non-permrtted events will not be allowed. �� CONTRACTOR/APPLICANT INF,fORMATION: � Name: � � '�l l�t-- �I'�,�j � ;,�,� State License# � -�� Expiration Date: L - v - � Lead Certification Number: Expiration Date: ,� (for work on homes that were constructed prior to 1978 �' '° Phone: 'j S�- � �-1 7� � E; S- (office) � j� � ��; 7� �� / (cell) �� _.,: <' ' Mailing Address: �,��- _ -��-� � ��,� r��, Cit : y�,� � ZIP: S S�6 � Contact Person: �� Applicant is: Contrac / Homeowner (Circle One) � Email and/or Fax: �$ ;� � PROPERTY OWNER INFORMATION: 4� Name: � �� i�7L.S ,rJ� � Phone (day): €� � Address: City: ZIP: �a Email and/or Fax � � ��=' PROJECT INFORMATION: � ' �',;:., Type of Project: Any earth movement may require � ❑ Door(s) ❑Remodel ❑ Fire Damage MCWD review&permits: �� Minnehaha Creek Watershed District(MCWD) � Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd " �� � ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 � Phone: 952-471-0590 ;;� ❑ Re-roof,other(specify) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 '� .k, ❑Window(s) www.minnehahacreek.orq � �; Overall Project Description: � Estimated Construction Valuation of Project(excluding land) $ � D , c�6 v u�� ;,� 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 altemative �� 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 infor ation is to annually update our records and records of other govemmental agencies '-;� re uired b law. If ou refuse to su I e inf ation,the a lication ma not be issued. #� � G�� ApplicanYs Signature: � Date: I �^ � � "') } � �-. Last Updated: 08-09-2011 � x�� � _ � _ � _ .. �... � ._a__ ..�.,_��. .�"