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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> � (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSIONj <br /> � � Mailing Address: ��S Q� /� <br /> � O PO Box 66 Permit number: �/ <br /> Crystal Bay, MN 55323-0066 Date received: <br /> � Street Address: Received by: � .� . <br /> y�, Gti� 2750 Kelley Parkway Plan review fee: <br /> `�kESHO�� Orono, MN 55356 <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: <br /> Job Site Address: Lf 3!5 �,ti� S � ; ,,� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 1'�a,n dVl.v [rP,.� ��..ti <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � �-7 5 .� (office) <br /> Maifing Address: �< < City: ZIP: 55 <br /> Contact Person: 1 M � L� ��� Applicant is: Contract r / Homeowner <br /> �C._.t1 I'� (Circle One) <br /> Email and/or Fax: �� ���a � � � 3 � ������ �h�p� �� <br /> PROPERTY OWNER INFORMATION: <br /> Name: � �; � ��� <br /> Phone (day): <br /> Address: Y 3!� /�e�s�i S }J� � City:�o ZIP� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect description: e�a.J .U„�_�-� <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 /> ❑ Re-roof, cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> ❑Window(s) www.mi neh hacr�esk.orq <br /> Estimated Construction Valuation of Project(excluding land) $ �� �n-,�� <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 o annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I t e i o e a lication ma not be issued. <br /> ApplicanYs Signature: Date: �f�//S <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />