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* City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> Qv 0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> t9kZS1404� Orono, MN 55356 <br /> . <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) <br /> Job Site Address: /_50 /(� � sgok hgg"f- A_5, -T— <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 /> CONTRACTOR/IPLICANT INFORMATION: <br /> Name: <br /> State License# �5����� Expiration Date: 3 (3 <br /> Lead Certification Number: / 7 l©7 S� -� Expiration Date: 16 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 52 - _ (office) (cell) <br /> Mailing Address: -7 7 - f L _ Or City: AJ.2c /ZIP: S J <br /> Contact Person: I�U'f u JE;L Applicant is: Contractor / Homeowner (circle one) <br /> Email and/or Fax: 0 eom <br /> PROPERTY OWNER INFORMATIO_�L_ <br /> Name: �y� �.�(StLl �zECkZ,RV <br /> Phone (day): <br /> Addres s: jS C7 ytJp}Zj-f{ E}©1 �fJ� (��S—f— City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ®,Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ eci Phone: 952-471-0590 <br /> Re-roof, others <br /> (specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Overall Project Description: f,i 0 V c Lk AC k 0 f Sum <br /> Estimated Construction Valuation of Project (excluding land) $ C)pp,©c) <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of thi ormatiorl, s to annually our ords and records of other governmental agencies <br /> required bylaw. If majiDFethe plication may of be issued. <br /> Applicant's Signature: Date: 2- <br /> Last Updated: 08-09-2011 <br />