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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 /> W <br /> PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> — 2750 Kelley Parkway Plan review fee: <br /> kESH0Orono, MN 55356 <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: p2,3 a (� <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: ��,( �,itSti ') <br /> State License# C 4-35/53 Expiration Date: 3/3///� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (-2 56--i-( o '1/ (office) <br /> Mailing Address: 3 ,f-/ City: 7&E,. ZIP: "5.5-41.z <br /> Contact Person: �., r,/� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: (e, <br /> PROPERTY OWNER INFORMATION: <br /> Name: Va•/Gl`rl-CA-c re/& <br /> Phone(day): t' go/ �j�j/ <br /> Address: � � ��j S 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) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> XI Re-roof,asphalt `Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> El Re-roof,other(specify) pj Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> / Fax: 952-471-0682 <br /> 0 Window(s) /CpKe`/"dfyL.kf £4SVitale www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 5 j 61g. <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: 2/ 4// 7 <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />