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City of Orono ,�`uilding Permit Application for Maintenance / Replacement / Remodel . ��.�e e�6��s, c�o�€°�; �e�6Q��, ��-��'9 ��e � �� '�U��R�.� ��S90�� Mailing Address: Permit number. `? ��0 PO Box 66 _ Crystai Bay,MN 55323-0066 Date received: Street Address: � y�, �` 2750 Kelle Parkw � �� . . Y Y� �� Plan review fee: . 9Ca • ��KESHO��G Orono,MN 55356 � Total Fee: Main: 952-249-4800 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 applicatlons wlll be returned. (P/ease print) GENERAL INFORMATION:��)�� , J �,�r_ � � � / Job Site Address: o I/ !-Y/�''G �'✓C ?r'r�v�-+'1�1 V�1� Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No ' 1/yes,a specJa/event permft is requlred wlth Pollce Departmer►t and City Council approva/60 days pdor to the eveirt Shuttle bus se►v�e wlll be requl�ed un/ess applkanf demonstrates suflicierrt on-site parkirrg is evailable. Non�ermitted events will not be allowed. CONTRACTOR/APPLICANT INFOR ATION: Name: pi,,�.- � �vi. '�jc,�r ��L,r-S State License# Expiration Date: ,�—�)_)�'�_ Lead Cert�cation Number: Expiration Date: (for work on homes that were constructed prfor to 1978 Phone: (cell) (office) ?v7 0 "'Z�)— 7g�1 � Mailing Address: D � rn , � City: — ZIP: � '� Contact Person: - Applicant is: Contractor Homeowner �ci�ie o�e� Email and/or Fax: ��g� �_ �� ,� PROPERTY OWNER INFORMATION: 9 Name: ,� �. �/l�A-�p` Phone(day): y � g D �' � � Address: � �Y S�yJ a�L ,�i City: ZIP: � r t p� Email and/or Fax: PROJECT INFORMATION: Overall ro'ect descri tion: Type of Project: Any earth movement may also require c�-'C hGr� MCVYD revlew�permtts: ❑Door(s) �.Re odel ❑ Fire Damage Minnehaha Creek WatersherJ District(MCWD) ❑Re-roof,asphalt ❑ Repair ❑Storm Damage 1g202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55381 ❑Re-roof,other(specfy) ❑Siding ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ � 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 rec�gnizes 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 rejed it until it is complete; • Some or all of the inforrnation 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 t�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 information is to annually update our records and records of other govemmental agencies r�uired by law. If ou refuse to su I the information,the a lication ma not be issued. ApplicanYs Signature: � Date: 3��/ Ovmer's Signature: �f�'1..( ��i.�f (�C�'1 Date: �LO I/.�J Last Updated:January 2015