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.. . � k,.< �* ,SK ,-:�'�'ts-`� �",�'�'s ;�k < .,. <br /> S �,. <br />� - ' City of Orono ��� <br />�� <br /> Building Permit Application for Maintenance / Replacement / Renovation �� <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) �� <br />�'�� Mailin Address: . ,g�� ] � � <br /> ��� PO Box 66 Permit number. ���JU�7v�/ .;:� <br /> � Crystal Bay, MN 55323-0066 Date received: ,—Z� �3 � <br /> �� ,�� Received by: ;� <br /> � � Street Address: q <br /> ti � 2750 Kelle Parkwa 'R <br /> �, G� Y Y �-M Ptan review fee: , <br /> t �, Orono, MN 55356 ` <br /> �kESH�� / �p��, �) t� <br /> Total Fee: o� <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: <br /> { Job Site Address: 3�,�(�� ����l,��l,-�c �z �r . C?r�;� c�, � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No � <br /> 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 '� <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. � <br /> '�� <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> � Name: � ��('-�(10,-C�/\ �.)1` \:�q —��iv�C�C'd��\�Qe_ ��C . <br /> � State License# ���Z(oS��j � Expiration D t : _ _Z�;, <br /> Lead Certification Number: ��� � �, �5 �� R._�.�g3/5-10-D��xpiration Date: �(�- -����i,� �, <br /> (for work on homes th wer constructed prior to 1978 � <br /> Phone: (cel �– Q (office) (o ��20 -- ��� � <br /> Mailing Address: � � it : (�rc ZIP: � <br /> Contact Person: ��� Applicant is: Contract / Homeowner (Circle One) �=,� <br /> Email and/or Fax: �j � <br /> �,> <br /> �,:; <br /> � <br /> �` PROPERTY OWNER INFORMATION: � <br /> Name: � '�`�� <br /> �� <br /> he <br /> Phone (day): (p�Z _ (G� � <br /> Address: �i(� �(Q�-����,,�� `��- City: Q(�;,�G ZIP: � <br /> � <br /> Email and/or Fax: F� <br /> �� <br /> PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: Any earth movement may also require � <br /> MCWD review&permits: � <br /> " ' ❑ Door(s) �Remodel ❑ Fire Damage � <br /> } Minnehaha Creek Watershed District(MCWD) +� <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage � <br /> �- 18202 Minnetonka Blvd �e� <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 � <br /> s <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 � <br /> ❑Window(s) www.minnehahacreek.orq � <br /> � <br /> � <br /> Estimated Construction Valuation of Project(excluding land) $ � ,GC�', ' `="�_ <br /> �: <br /> � <br /> i: 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 hisJher 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 /> rejec t i t un ti l i t is comp le te; >. <br /> _ �, <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 ';'i <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I t e informa� n,the li not be issued. � <br /> ; <br /> ApplicanYs Signature: Date: f - Z�7– (.� <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 '�` <br /> s �-S <br />