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<br /> City of Orono
<br /> • Bu�ding Permit Application for Maintenance / Replacement / Renovation ��
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> �O� Mailing Address: Permit number: � '
<br /> � O PO Box 66 /� :
<br />�;;: Crystal Bay, MN 55323-0066 Date received: � V �� — �
<br /> �```' Received by: `
<br /> Sfreet Address: �
<br /> Ap i, y� � 2750 Kelley Parkway Plan review ee:
<br /> �' Orono, MN 55356
<br />' t�kESH�4� �—'��� �5 ?
<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: �"� � 7 � �/�i��i�� /�� �
<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 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 />�'a CONTRACTOR I APPLICANT INFORMATION: �
<br />�� Name: � -
<br /> , 7" - �c�2 s� �..,1r'":�f: ,i
<br />"�' State License# /� �,�' Ex iration Date:
<br />,.,, � C C 5 5� � P � i�r
<br /> ' Lead Certification Number: ivt�T �I7�3 -�/ Expiration Date: ����
<br />� (for work on homes that were constructed prior to 1978
<br />� ` Phone: (cell) 7�.� . �33� f�33 (office) '�L"s 2�/5! -1;�&/
<br />��^ Mailin Address: �'�' Cit �- ZIP: 5 s`�{��
<br />�,�, 9 /Z - 23 ,� n/ Y� y .
<br />�'�; Contact Person: �,;,,� ,�'�.. Applicant is: �"ontract / Homeowner (CircleOne)
<br />��k' Email and/or Fax: �<�� � �
<br /> 't-4�.,,, �u 'oe r, � vJ �'+'� C �'�,L.�"-�►� i VdZ s. C.c.�:r'1
<br />�;u;�' �
<br />�: PROPERTY OWNER INFORMATION:
<br />�° Name: � � c 1-/ ri ��2/L �/1�`f s��' Ck l
<br />�,"�:
<br /> ,,. Phone (day):
<br /> � Address: � ��v Cit :
<br />� r; Z7?C, �A � 4- Y �'/l-�ti-D ZI P: y s�� y�
<br /> rs:x' Email and/or Fax:
<br />>.:�;.
<br /> s.:;
<br /> PROJECT INFORMATION: Overall project description:
<br /> w,t,` Type of Project: Any earth movement may also require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> �Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br />� Y' 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 /> x, ' Fax: 952-471-0682
<br />�.• ❑Window(s) www.minnehahacreek.orq
<br />�z� Estimated Construction Valuation of Project(excluding land) $ 0!) , '•!'
<br /> �:�:
<br /> �`' APPLICANT ACKNOWLEDGEMENT:
<br /> ,,:;
<br />�"" • Agrees to provide all information required or requested by the Building Department;
<br />�:
<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 />�i intended use of this information is to annually update our records and records of other governmental agencies required by law. If
<br />��i ou refuse to su I the inf mation,the a lication ma not be issued.
<br />�^,
<br />�, ApplicanYs Signatur � � Date: �3 Z 3 l�
<br />��;'
<br /> Owner's Signature: Date:
<br /> Last Updated: 03/06/2013
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