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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 /> ��f V Mailing Address: Permit number: p(O/74.10/ Z 7 <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: g/7/17 <br /> Street Address: Received by: <br /> L' 2750 Kelley Parkway Plan review fee: a6.. <br /> ,20 <br /> 4kFsri00" Orono, MN 55356 X1-90p1 3' <br /> Total Fee: it ` ` 9" 9 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 1. <br /> 1 <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: S �j(' �r�\r' S �d kA l�G.SL <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: N.Q70- Er c,‘ C(vS 1.) (0r1 <br /> State License# ‘ ,C(‘)(02) In Expiration Date: <br /> Lead Certification Number: lk)r)•1., I y - I 114 -a Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: a,ti jt4rui h �� Ci d ZIP: S533 <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> nA <br /> PROPERTY OWNER INFORMATION: �J <br /> Name: h,\\1� 1( ICO\� <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) 'emodel 0 Fire Damage MCWD review&permits: <br /> yr <br /> ❑ Re-roof,asphalt ❑ Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar <br /> 0 Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) 0 Siding ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 1 5 61 00(.) <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 w generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this infor• Pon '. nnually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the io the application may not be issued. <br /> Applicant's Signature: I <br /> Date: ___02.7i iCS <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />