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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 EXPA�: <br /> O Mailing Address: permit number: 6I�'���,,q <br /> � �O Po Box s6 �` —I <br /> Crystal Bay, MN 55323-0066 ,� / Date received: <br /> �l" `x./ <br /> Street Address: "� � Received by: <br /> ti�, � 2750 Kelley Parkway ✓� ���� Plan review fee� <br /> t Orono, MN 55356 � <br /> �kfSH��� ���� � <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 futl and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ���� '�c� }-t,� ,_.,��c, � �2 a� �1 <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 approva/60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil!not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Pa��-r��s �I . YJ�s���n L1,C. �����u C�s�('��w- <br /> State License# ��L��-7-1� (� Expiration Date: m 3��l�w��? <br /> Lead Certification Number: N�T- �t`�S�l� � - 2 Expiration Date: y�Z�,� Zo Z� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (p�Z-g�t� -o�t�i� (office) ��L_ c.�2� _ y y y c t <br /> Mailing Address: ?S �r\�e-�- rz �- 5�.:,�-� 1 n`�1 CitY: ,�v� I S, ZIP: ry $-S'yns- <br /> Contact Person: ��r�� Applicant is:C ontra�tor._�/ Homeowner �a��ia o�e� <br /> _.._ <br /> Emait and/or Fax: ��tJ� (� r�'�42iN�Rs'-i �l:S�U�.� . �'='Y'"` <br /> PROPERTY OWNER INFORMATION: <br /> Name: L y�, t�.'.o �- 5 t:s y t�t'�y <br /> Phone (day): C���- t�'7 I-f�V\ln <br /> Address: U c,�� �� r}e,r.�...��U � rz��� City: J���, � ZIP: �S 3 S�� <br /> Email and/or Fax: `�,,��y __��-��-�,y � ,�.�yn ,��r� <br /> /VI►�St�Yt �3Er�n-:x:�,•, �. N`w t=.t��P►..��� <br /> PROJECT INFORMATION: Overall pro�ectdescription: i=.��iN� 2cr,7 �. Nt� �z�-i=p�q�� ,� sTc,�� W!�� ��►�.�►•�t� <br /> I'ype of Project: Any earth movement may also require <br /> �Remodel MCWD review&permits: <br /> ] Door(s) ❑ Fire Damage <br /> ] Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ] Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> I Re-roof,other(specify) ❑Siding ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.og <br /> timated Construction Valuation of Project(excluding land) $ Ls,pov •��G <br /> PLICANT 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 /> iYs Signature: G�� �`�— Date: `��I Z)17 <br /> signature: S�P 1 51n17 <br /> ������/ Date: _ _.9���I 7 <br /> ed:�anuary 2o�s CITY OF ORONO <br />