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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) p <br /> Mailing Address: Permit number: 76 !� <br /> \ PO Box 66 <br /> 4 <br /> �� i ,; <br /> Crystal Bay, MN 55323- 0 Date received: /� —�G1 — ) <br /> Street Address: OL I j 0 2017 Received by: y azo <br /> 2750 Kelley Parkway Plan review fe <br /> �gKesHo�`` �b Orono, MN 55356C11Y OF ORONO <br /> Total Fee: �• <br /> JMain: 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: Z So S o /d a C, rd , w a 'Z <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes Of 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 se ice 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: L .'`7 CJC-J Co c, <br /> State License# t xG 7 Z S 9d l Expiration Date: 3 / 'Lo lq <br /> Lead Certification Number: NlA-T _ S-,?q 2 N Expiration Date: io Z_- u, <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) -7 ; 1z d 3 s,, 3 (office) 3 o o • D-73 <br /> Mailing Address: '77.1 Ham, 3 City: i'i , „ ZIP: <br /> 'FYooL <br /> Contact Person: b `„"7 Applicant is: ontra to / Homeowner (Circle One) <br /> Email and/or Fax: p 4 , K c��r- -J s C o co-k <br /> PROPERTY OWNER INFORMATION: <br /> Name: K: 1< Sttf_" ,a <br /> Phone (day): 7 S"2, Y7�. q7Z <br /> Address: 2� s ort br a_�L. ,1 . City: Wlty Z o'�•� ZIP: S-5-3`t I <br /> Email and/or Fax: )el co ue P K sn c ^� <br /> PROJECT INFORMATION: Overall project description: Qc-OccK <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) E0 Remodel El Fire Damage <br /> 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 V1 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) $ /i., 000 <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 lication may not be issued. <br /> Applicant's Signature: Date: 1012- <br /> 1 <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />