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P��,�,n,�� Q-e N��o —r�-o i rn� l��..��' �l�//��4'�U C i ty of O ro n o �°� � Butlding Permit Application for Maintenance / Replacement / Remodel (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) �O�O Mailing Address: Permit number: 20� -,>r— PO Box 66 Crystal Bay, MN 55323-0066 Date received: — — � rj Street Address: Received by: y�, � 2750 Kelley Parkway Plan review fee: �' Orono, MN 55356 `�kfSH�� 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 I FORMATION:�., / Job Site Addr s: L. � (. j� � ;�� Will this be a Pa de of Homes, Remo elers Showcase Home or other Display Home? ❑ es [� No If yes,a special eve ermit is required with Police Department and City Council approval 60 days prior to the event. huttle bus service will be required u ss applicant demonstrates sufficient on-site parking is available. Non-permitted events wil ot be allowed. CONTRACTOR/APPLI NT INFQRMATION: Name: � State License# piraf n Date: Lead Certification Number: E p� tion Date: (for work on homes that were con ucted prior to 1978 Phone: (cell) ' (o ? ,J� Mailing Address: ity: ZIP: Contact Person: A p an � . Contractor / omeowner �c��ie o�e> Email and/or Fax: PROPERTY OWNE INFORMATION; �` Name: � Phone (day): � / - Address: Z�` • �( City: (��p ZIP: �,�,�,3 f Email and/or Fax: '�( � Q�� PROJECT INFORMATION: Overall project scription: �l,l�l �C�� Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restor ion ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof,other(specify) ❑ Si ' g Other:(specify� Phone: 952-471-0590 Fax: 952-471-0682 indow(s) � j www.minnehahacreek.orq Estimated Constructio aluation of Project (excluding land) $ C� APPLICANT AC OWLEDGEMENT: � • Agrees to p vide all information required or requested by the Building Department; • Certifi that the information supplied is true and correct to the best of his/her knowledge. The app' ant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the st 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 la s either private or confidential. Private data is information which generally cannot be given to the public but can be given to the s ject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. O purpose and intended use of this information is to annually update our records and records of other governmental agencies requir by law. If ou refuse to su I ' fo tion,the a lication ma not be issued. ApplicanYs Signature: Date: � . Owner's Signature: Date: Last Updated:January 2015