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� ���� �- 8 z� <br /> � , g l3 � 2� <br /> City of Orono Q � J <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> '"� Mailing Address: Permit number: �O` � <br /> PO Box 66 <br /> ���'��O <br /> � Crystal Bay, MN 55323-0066 Date received: —�,3 —�3 <br /> Street Address: Received by: ,Q. <br /> y � 2750 Kelley Parkway Plan review fee: <br /> F Orono, MN 55356 G <br /> rqkfSNn�� �U�7 d • �D T <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�'� ,� i� e�, �,�,�� ���:c� c� . � ��� �``�'`�% S � 3 5 �� <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: r�� �,,� C:-�,ts c;,. <br /> State License# �L,�3 �-���, Expiration Date: 3 3 �� <br /> Lead Certification Number: �,� �T - I C�`i�j� - � Expiration Date: � � �� ( ��, <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � 1 _ g�i� -��{�7 c� (office) � ��- - `�Z� -�-t �+ u �i <br /> Mailing Address: ,�-r� �ti�.��z�r St r t��t �t e. 1 i�`� �'.Ity: (�\;�.,.�z�j m �,1 Z�P: S S �;S" <br /> Contact Person: q,����L,s�6 c;-.., Applicant is: _ntract� / Homeowner �c�roia o�e� <br /> Email and/or Fax: ��;,.t ��� �,,;,�,N�: r��D�-�s����. �2;��- <br /> PROPERTY OWNER INFORMATION: <br /> Name: -�r���� s L<r,.�'�� L ; ��( <br /> Phone (day): �S 1_- �i'�1 - ��-�) w <br /> Address: �`�v i%..� �rec, w���� ��_.<_� City: C:�-��..,� ZIP: 5i�3;"C_. <br /> Email and/or Fax: <br /> PROJECTINFORMATION: Overall ro�ectdescri tion: ��^r �����-� �r -��� r `r <<�a `��> ��``�°`" '�� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) (�Remodel ❑ Fire Damage <br /> MCWD review 8 permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑Storm 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) $ :�C�,C:E-�c'. <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 /> ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: �� Date: �(13�1� <br /> " �.1 ; , <br /> Owner's Signature: ���' �'ut c.c- � �-• Date: ���; � <br /> Last Updated:03/06/2013 � <br />