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City of Orono <br /> Building Permit Application for Maintenance/ Replacement/ Remodel - Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> A, Mailing Address: <br /> PO Box 66 Permit number: ®/Q1—L'162 <br /> Crystal Bay, MN 55323- 66 b• Date received: U /' <br /> Street Address: <br /> Received by: `ti Mr <br /> A, 2750 Kelley Parkway Plan review fee: 4r (OS, <br /> Orono, MN 55356 <br /> `gKFSHO�, /- --O/[) <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: <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/APPLICANT INFORMATION: <br /> Name: \_ Z, � �.\�,,_, ' <br /> State License# � r�c�e� Expiration e: <br /> Lead Certification Number: W ts� _2y��—��--Z Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: \� �-L — \ City: ZIP:SS <br /> Contact Person: �� �c1 Applicant is: lqontracto / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: y��o� © City: ZIP: <br /> Email and/or Fax: n <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ Sb Zai <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 to annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the information the application may not be issued. <br /> Applicant's Signature - --�\ Date: cit) <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />