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� City of Orono ��- � � �a� <br /> Building Permit Application for Maintenance 1 Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O Mailing Address: Permit number: 0�0 t 3 — (�� �3 <br /> � N � Po eoX ss <br /> 0 Crystal Bay, MN 55323-0066 Date received: /�" �I-� <br /> �, � I Street Address: � Received by: ,CJ <br /> ti � �C{� 2750 Kelfe Parkwa �� <br /> Y Y �'O Plan review fee: ) Z,7 <br /> �lqkFSH� G II O Orono, MN 55356 D � <br /> �� Total Fee: c� 3� �� � 3� <br /> Main: 952-249-4600 Fau: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be compteted in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: ,,� <br /> Job Site Address: 2 �3 S �V�J 2 •—f-; .�,���-� ./��.���� �l��J�✓Ur �r� -� � 3 � � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o <br /> If yes,a special event permit is required with Po/ice Department and City Council approval 60 days p�or to the event. Shuttle bus service wil/be <br /> requinnd unless applicant demonstrates sufficient on-site parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: J,,N �u��; � �L� <br /> State License# � � �,,3 �y-i Z Expiration Date: Q 3 � �/. ZG/�{- <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior fo l978 <br /> Phone: (cell) (o i 2 - Z�'Q - �''1�1'7 (office) �,i � -3 Ll - ;�,3 S'� <br /> Mailing Address: �Q 1 �v��L�� � s �,,�,-� ��,,ur� � �'Lt� � Ci : ���'��-�,!� ZIP: Ss�S , <br /> Contact Person: �,�,�� ,�j������q Applicant is: Contractor / Homeowner �c��ie o�e� <br /> Email and/or Fax: ���.,��� � �� /���,�< < «,�� <br /> PROPERTY OWNER IN�ORMATION: <br /> Name: ��Cry ('y� �T' ����L'D� <br /> Phone(day): ��L� �('�� - � � � Z <br /> Address: 2 r z t,c: � �7 a��t°�.�i,� �l� c.�c�: CitY: +l�d��� /;'17ZI P: ��� � 5 Sv <br /> Email and/or Fax: f�-CF,!� I�l C�U >�' c�' b �c��/4 i��i�'��^�S i r;�(�. C'�,� <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <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 /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) �iding ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 � <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ Z ��,I�'�I �� <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 inform � n which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this infor ati is to ually up e our records and records of other governmental agencies required by law. If <br /> ou refuse to su I t i rm ion a lica' ma not be issued. <br /> ApplicanYs Signature: � ��� �� Date: Ib ' Z�"�/' 3 <br /> Owner's Signature: Date: ��i - � � - 13 <br /> Last Updated:03/06/2013 <br />