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City of Orono 40 <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> j Mailing Address: Permit number: c7,90/3-ease-7, <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: y-30�� <br /> Street Address: Received by: -� <br /> yN. 2750 Kelley Parkway Plan review fe:: <br /> e� �' Orono, MN 55356 <br /> �� rS�o Total Fee: -,h c, 57-/-, <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: 3 35 O(41 Cr f ( Aty ,J �/ <br /> Job Site Address: J h('� '� <br /> Will this be a Parade of Homes, Remodelers Sho case Home o other isplay Home? ❑Yes E -N <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: 1 Cr off' 6,,,LcL.-f y,� c kre'l 4 <br /> State License# ii-3 Expiration Date: 7-17—/'c-/ <br /> Lead Certification Number: 4�'t —b((y IL-1 Expiration Date: 1—.26—if' <br /> (for work on homes that wee constructed prior to 1978 <br /> Phone: (cell) 6(,._ 2 ) _ 74,7$ (office) -76#",-- '(.2- — o/'y <br /> Mailing Address: ' O ! ic4 ' - /j/' City: /„ /e (n',v- ZIP: , 5-3- <br /> Contact Person: tc Jo 14.4 Applicant is: ontract•Ta. Homeowner (circle One) <br /> Email and/or Fax: ) IV 20 s/ egg I c.�JC P;at ^ Ga/1 f 76 G a✓Vl <br /> PROPERTY OWNER INFORMATION: <br /> Name: ?//n,` K et e <br /> Phone (day): <br /> Address: 5 at/ ,r)(s I <br /> f , /? y /1t 5, City: Of(3^t7 ZIP: 5-5-if-4 <br /> Emailand/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ElDoor(s) 0 Remodel EIFire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt 0 Repair ❑Sto Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar l3' torationater Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) IDSiding ElOther: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> El Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 5--e .9 .6 . 7 3 <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 Ito the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application Ipeing aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is complete; I <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 inf ation,the a BJisetitsn may not be issued. f / <br /> Applicant's Signature: Date: "�,( —.10 - ` 3 <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />