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City of Orono ��ilaing Permit Application for Maintenance / Replacement / Renovation �;� (No structural expansion. Only windows, doors, siding, re-roof, etc.) �"„ �O� Mailing Address: Permit number: ' `""�, O PO Box 66 ��' Crystal Bay, MN 55323-0066 Date received: '� ��j � � Street Address: Received by: � `' ; 2750 Kelley Parkway Plan review fee: ��. y�� ; qk�SHO�F,�' Orono, MN 55356 y, + 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: � �� 27 3� � h.�� c�� ; �,: Job Site Address: �� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No �� If es, a s ecia/event ermit is re uired with Police De artment and Ci Council a roval 60 da s nor to the event. Shuttle bus service will be #� ��k�� Y P P q P tY PP Y p � ; �.. required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. '�`. rr t �;.3 �x CONTRACTOR/APPLICANT INFORMATION: �`� C � Name: �,. - c:�tii L(.._ C__. ;� �� State License# C,� Ex iration Date: Z�i � � � ��7 �1E:� P� 3 -31 { � �` Lead Certification Number: Expiration Date: �{ �,,` (for work on homes that were constructed prior to 1978 `'_ � Phone: (cell) —7 (�,3 — —75 (office) � `�� Mailin Address: Cit " � ZIP: jS 3� g I `� (•� Y ua2ns�� c. � �" Contact Person: Applicant is: Contracto / Homeowner (Circle One) x� Email and/or Fax: � � '� � �` PROPERTY OWNER INFORMATI N: � F�' 1 " . f.� Name: � �; ri� �.` Phone (day): �kk' � Address: Z�'�� ,�� City: �a�:1v ZIP: 553�3 / �� Email and/or Fax. � :s� z�y� �;� PROJECT INFORMATION: Overall project description: �; �,� Type of Project: Any earth movement may also require ; ` ❑ Door(s) �emodel ❑ Fire Damage MCWD review&permits: �; �� &�y ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) y ��` 18202 Minnetonka Blvd �'� ,�,_'; ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 =� ❑ Re-roof, other(specify) �}.Siding ❑ Other: (specify) Phone: 952-471-0590 ` �„;' Fax: 952-471-0682 ��.; �Vindow(s) www.minnehahacreek.orq � : � �,�; Estimated Construction Valuation of Project(excl ding land) $ (� d t� � � �`; � APPLICANT ACKNOWLEDGEMENT: .:.� "�t„' • Agrees to provide all information required or requested by the Building Department; � � �h� • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are ' ��, �a; solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to r� .��;a;; 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 � �'M1 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 which generally cannot be given to either the public or the subject of the data. Our purpose and `� + :: intended use of this informa ion is ft��nuall update our records and records of other governmental agencies required by law. If a �� ou refuse to su I e in ation, the a lication ma not be issued. y� �, ��' ApplicanYs Signature: Date: _ ! L� '��Z ' Z c,�"� � �5; y3 �`�', Owner's Signature: Date: Last Updated: 03/06/2013