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, • �� <br /> �'� ��,/h <br /> '� , �` ����' '.��,I.�i <br /> . � �\ � t � <br /> City of Orono <br /> Building Permit Application for Maintenance/ Replacement/ Remodel—Residential ONLY <br /> (i.e.windows, doors, siding, re-roof,etc.—NO STRUCTURAL EXPANSION) <br /> �� � Mailing Address: Permit number: L/[/ � <br /> �\ PO Box 66 <br /> i� � � Crystal Bay,MN 55323-0066 Date received: ���'�� <br /> � � Str t Address: 7�—' <br /> `i �i 50 Kelley Parkway�L.����GC f I eview fee: � • �� � <br /> `�\ t � Oron , L -�. <br /> _�,______ _- <br /> \kESHo�' ____-- <br /> � Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: ��p �,f� r� O4 Of p✓10 �� ���`� <br /> Job Site Address: � <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home7 ❑Yes No <br /> /f yes,a special event permit is required with Police Departmenf and City Council approval 60 days pnor to the event. Shutt/e bus service ill be <br /> required unless applicant demonstrates su/(icient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �J'�}� .�-�f 5 o c;o,'f'G�S <br /> State License# \ C po � 3$O Expiration Date: �'�. '?j� , 2v�� <br /> Lead Certifica;ion Number: ���— 9��y�- 2, Expiration Date: p(�, p�, Z�Z� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) to�Z, Z�Z, �jo�-7 (office) qSZ, �jc.�5 . 9yc.(e <br /> Mailing Address �g�1Z �� City: (�,�� y ZIP: y � <br /> Contact Person: L Applicant is: Contractor / Homeowner �c�.�ie o�a� <br /> Email and/or Fax: jw;�\ G � S-}y�L�,� �np,�y tS . C.ov✓� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �'�`o�v�L}}'e� �C�LN�S <br /> Phone(day): °5�2.�c� �. �'e�7 n <br /> Address: �(o�1 �o J'1''�+ �wY� 1Znw�X- City: (�✓'e v� o ZIP: rj�j Z S �e <br /> Email and/or Fax: q,y►i-o �h�,�,.j.L � ,iyL. �„M <br /> PROJECT INFORMATION: Overall project description::���5��d" ��/�-S� IXd�F �l�^T�+ l�✓�,d�t�� <br /> Type of Project: Any earth movement may also require <br /> �Door(s) �Remodel ❑Fire Damage MCWD review 8 permits: <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952�71-0590 <br /> Fax: 952-471-0682 <br /> �W indow(s) www.min�ehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ � �s�t7017 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually upci'ate our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the i form tio ,the " lication ma not be issued. <br /> ApplicanYs Signatur j��� ���� Date: $•� . � �o <br /> Owner's SignatErre ����� Date: <br /> Last Updated:January 2016 ����//' <br /> GL�/ � ��, <br />