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City of Orono <br /> Bu�lding Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O�O Mailing Address: ' (� Permit number: ��� - d��/ <br /> PO Box 66 „VL <br /> Crystal Bay, MN 55323-0066 ��" Date received: p� -� <br /> Street Address: ,�{ ��� Received by: <br /> y� G` 2750 Kelley Parkway� �� � Plan review fee: <br /> Orono, MN 55356 � ���' � <br /> `�kFSH��� Total Fee: O� <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: ,$- Uc� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> !f yes, a special event permit is required with Police Department and City Council approva/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: � 2 Q �� s,a,.� <br /> State License# �C ��..f q �, 7� Expiration Date: .3 3 a�,� ' <br /> Lead Certification Number: �,�;}.T-�-5 77S-� Expiration Date: ��a���}�,s-- <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (���_L��] -S��y�U (office) C �1 S�� y 7�/-7/�1 � <br /> Mailing Address: -� � n o , ��,� City: �� �,�� t��,,t ZIP: S-S- 3 � / <br /> _���=� �—.T—fi� f S <br /> Contact Person: �i T r. --5-���5`�,�, Applicant is: on rac o / Homeowner (Cirde One) <br /> Email and/or Fax: -�- ,� � '���,�L .�l S� , C�c4�►�l <br /> ��As—� t,N � I_A Lj E C�7u,�- <br /> PROPERTY OWNER INFORMATION: <br /> Name: � LvL �' � ��-=<j ��, �'���-P <br /> Phone (day): ��, ,3 `-y 7�'r- s �v <br /> Address: � ��'3 ,�K (J � City:��,�,, v ZIP: S S 3 c. cJ <br /> Email and/or Fax: N iGoLC� �;��j��aC(� , b c•v� <br /> PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: Any earth movement may also require <br /> �Door(s) Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt Repair ❑ Sto�m Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <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) $ � �� •o <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 inf a ' to nually pdate our records and records of other governmental agencies required by law. If <br /> ou refuse to su I �e info "at' n, e a I� ation ma not be issued. <br /> Applicant's Signature: � f � �� Date: v� .S✓ �c� <br /> Owner's Signature: Date: a\��`� <br /> Last Updated: 03/06/2013 <br />