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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 /> t V Mailing Address: Permit number: �j/7D-07?S` <br /> W PO Box 66 <br /> Crystal Bay, MN 55323-0Q{fi61 Date received: /`4,_) 7 <br /> Street Address: �'� Received by: —J <br /> y� L� 2750 Kelley Parkway 1/ Plan review fee: <br /> `AESHO�� Orono, MN 55356 /"/ 8.5Total 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: ,7 <br /> Job Site Address: �' ��i"Cf1' <br /> �� 7 c`( /e - c � 21 ; /L (l-�� s w <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? E Yes 1 JVo <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/APPLICANTIN ORMATION: <br /> Name: 2e3 /t J if-ci4, i fI iict,7'7cO-i LLc— <br /> State License# ?4�/ Expiration Date: . <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (Pla — 1'6,5-- 960 '7 (office) 76,3- 4i79 -/3 j 3 <br /> Mailing Address: y^ G - , City:/1//e ZIP: 75-8 <br /> Contact Person: / ' ko L Applicant is: t.n racto / Homeowner (Circle One) <br /> Email and/or Fax: ah/A.3/c_e,, & 60 /nc- cf <br /> PROPERTY OWNER INFORMATION: <br /> Name: e v c <br /> �. ¢ , 4 L <br /> Phone (day): 40/:2 - 96. cf - 74, 4L(74 <br /> Address: 6,t6- dj-ch1z-i; t-(_ ,a.4-- , CE. City: - -z ZIP: SS � 5-Z. <br /> Email and/or Fax: /1/, <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) emodelMCWD review&permits: <br /> 0 Fire Damage <br /> ❑ Re-roof,asphalt El Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> El Re-roof, cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ElSiding ❑ 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) $ j d 2C) <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 t - 'nfo ation,the application may not be issued. <br /> RECEIVED 7 <br /> Applicant's Signatur-: ` Date: 7/i)�,/ <br /> JUL 0670at .1/. <br /> Owners Signature: <br /> Last Updated:January 2016 CITY OF ORONO <br />