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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> • (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> CoAMailing Address: Permit number: 1J3/ 5 — 60 2 5fe2 <br /> O PO Box 66 _ <br /> Crystal Bay, MN 55323-0066 Date received: / 5�/� <br /> Street Address: Received by: �� <br /> A <br /> G` 2750 Kelley Parkway Plan review fee: <br /> F <br /> t Orono, MN 55356 3 /,, <br /> �kESHO� lO( 2 c <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: I ?6\ 0 r-0,1c3 L.-0.n 'E_r. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yeso <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus rvice 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: 4<<{-4,L, {-4-0\S .J• <br /> State License# I Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) tv 1 Li e10 - S 3 (office) <br /> Mailing Address: 3131 co-t-fct,i e LQne— City: F'n-t--,,_ ZIP: ...,, 0 5 <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: korai 1 h0kelt„L.in co Liall,n_c0ri,1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: :j<LI(y d Clam Il\&c. Vf; (Ickv) <br /> Phone (day): <br /> Address: 3 ri Oro r\o L--v—e._ City: (A)61.1.2_,.. tz. ZIP: 5`-5 3 5 i <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 1=1 Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt /❑ Repair I=1 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 ❑ 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) $ a°1 b O 0 . ' <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 information,the application may not be issued. <br /> Applicant's Signature: ' Date: <br /> V <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />