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� � � r ..� City of Orono � ry Ruiiding Permit Application for Maintenance / Replacement / Renovation �� (No structural expansion. Only windows, doors, siding, re-roof, etc.) ,�: � Ar Mailing Address: Permit number: � �� 0�yO PO Box 66 ��3 - Crystal Bay, MN 55323-0066 Date received: � 3`' .�n �'t' Street Address: Received by: � ° y � 2750 Kelley Parkway � Plan review fee: t? `�t �' Orono, MN 55356 � �k�SH�� 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: '� Job Site Address: �� C�� ✓� � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No � 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/APPLICANT INFORMATION: � Name: ��n c l�`�_ �Y�T�J`. d('_S — �n�� a State License# �� j� �,j� Expiration Date: �_ �'� Lead Certification Number: Expiration Date: �; (for work on homes that were constructed prior to 1978 �;; Phone: (cell) C�.� — ��— % }'"7 7 (office) �5�'��y��—�'dG�� Rp Mailing Address: a�;j7_S �� y� City: � ��w� ZIP: �- _�3�3� � �� Contact Person: �5 cj( S � �� Applicant is: on� ctor / Homeowner �c��ae ooe� �; ` Email and/or Fax: � � �r L� �C —� 7 , � �= ✓r',, PROPERTY OWNER INFORMATION: ��' "� �� , / � Name: � � 7�`� � �l�6t// �� ;� Phone (day): �Ja�-3 a �j — �j d 3 � �� Address: City: ZI P: � Email and/or Fax: � PROJECT INFORMATION: Overall pro�ect description: � ��:, Type of Project: Any earth movement may also require � ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: s �+ �: ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) ��," W 18202 Minnetonka Blvd � .� Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ,� yt Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 ��' Fax: 952-471-0682 � ❑Window(s) www.minnehahacreek.orq � Estimated Construction Valuation of Project(excluding land) $ /� ��G �� � �� ;�a .7;; 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 that they are '� solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to � _ reject it until it is complete; � ��, • Some or all of the information that you are asked to provide on this application is classified by State law as either private or � '' 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 hich generally cannot be given to either the public or the subject of the data. Our purpose and ' intended use of this informati is to ann Ily update our records and records of other govemmental agencies required by law. If � ou refuse to su I t info ation, the lication ma issued. ;� Applicant's Signature: Date: /'G - Zj—i _3 Owner's Signature: Date: �,: Last Updated: 03/06/2013