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City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) 0 Mailing Address: Permit number: PO Box 66 Crystal Bay,MN 55323-0066 Date received: ��j� Received by: Street Address: 2750 Kelley Parkway Plan review fee: 11 tiff �� Orono,MN 55356 Ile, gkESHo,Rt Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: I ii Oi1 Job Site Address: �,t(, Q � a e?0W No Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes 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 required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR I APPLICANT INFORMATION: Name: set Expiration Date: ri State License# Lead Certification Number: Expiration Date: ! (for work on homes that were cons ructed prior to 1978 (office) Phone: (cell) ZIP: Mailing Address: r City: om Applicant is: ontracto / HHomeowner (Circle One) Contact Person: Email and/or Fax: PROPERTY OWNER INFORMATION: Name: Phone(day): City: ZIP: Mae Address: Email and/or Fax: � rk -- PROJECT INFORMATION: Overall pro'ect description: Any earth movement may also require Type of Project: MCWD review&permits: ❑Door(s) ❑Remodel Fire Damage Minnehaha Creek Watershed District(MCWD) Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd Water Damage Deephaven,MN 55391 LRRe-roof,cedar ❑Restoration ❑ g Phone: 952-471-0590 f,other(specify) ❑Siding ❑Other:(specify) Fax: 952-471-0682 ❑Window(s) www.mi n hacreek.or Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT:• Agrees to provide all information required or requested by the Building Department; Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes t7they• solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alter reject it until it is complete; or plication is classified by State law as either private Some or all of the information that you are asked to provide on this ap . confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually u date our records and records of other governmental agencies required by law. If you refuse to su I e i ation,th ""iic 'on a not be issued. Date: Applicant's Signature: w. Owner's Signature: Date: Last Updated:03/06/2013