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fi • City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) � Mai/ing Address: Permit number: � ��0 PO Box 66 Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: � �' 2750 Kelle Parkwa y�, G� Y Y Plan review fee: Orono, MN 55356 `�'�ESHO�� 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) `�' GENERAL INFORMATION: Job Site Address: °'` ,*, Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No k�; If yes, a special event permit is required with Police Department and City Council approval 60 days pnor to the event. Shuttle bus service will be '' required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. � �? CONTRACTOR/APPLICANT INFORMATION: Name: ,��, '.��/ �j �,� State License# C�3 ps' Expiration Date: �_ 3 � — Zo/5� F� Lead Certification Number. _.. a �.j�_ Expiration Date: -7_�_��s K� H� (for work on homes that were constructed prior to 1978 y Phone: (cell) (P/�_��j�-/�� (office) 76 3—�ff�f-�g S ; Mailing Address: p , C�' City: ZIP: S�l �; Contact Person: o � � ve�� Applicant is: ontractor Homeowner (Circle One) � :� Email and/or Fax: �,� ' (� h�,rn.e�'a�cA-i�CS7� ox-•�"� a PROPERTY OWNER INFORMATIQ�V: Name: (�P b r�., K o S 2,f-t� Phone (day): (�a — 7/0 — ��d 9 Address: 3/ f38 it/or'•�l,S�.or� [Jr�ve- City:(�/ay'u.�- ZIP: �-S'��/ Email and/or Fax: PROJECT INFORMATION: Overall pro�ect description: `;-� Type of Project: Any earth movement may also require �� MCWD review&permits: "� ❑ Door(s) ❑ Remodel ❑ Fire Damage �; �] Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) ; 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ 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.orq °' , ;, �� Estimated Construction Valuation of Project(excluding land) $ C� o� � � °� � �� 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 �X intended use of this information is to annually update our records and records of other governmental agencies required by law. If ou refuse to su I the inf 'o , e a lic tion not be issued. ApplicanYs Signature: �-�' Date: �—/��l J� :� Owner's Signature: Date: ;`: �� _4{ Last Updated: 03/O6/2013 - -�