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. �;��I� . . � � ?': +t r 0. '�� 4 " 3 <br /> § <br /> �. ,T ' <br /> a � <br /> - ` City of Orono <br /> Building Permit Application for Maintenance / Renovation �� <br /> (windows, doors, siding, re-roof, etc.) � <br /> � Mailing Address: � <br /> � �.,�,� PO Box 66 Permit number: l —('� �� <br /> � <br /> 0 Q Crystal Bay, MN 55323-0066 Date received: /� // a; <br /> I r� f�;�,r� Received b �`� <br /> 1� � ., s, StreetAddress: Y� � <br /> ��'�n ; �'�� Gti�' 2750 Kelley Parkway �' <br /> �t9rf 4� Orono, MN 55356 Plan review fee: ;�: <br /> SH� � <br /> Total Fee: ���,p� � <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: L <br /> Job Site Address: ��,� �S f �/ �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 approval 60 days prior to the event. Shuttle bus sekvice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �,' <br /> CONTRACTOR/APPLICANT INFO ATION: � <br /> ; Name: �,.'t - ) yL.. <br /> State License# 2 e r��,Q" Expiration Date: � 3� � L. � <br /> y Lead Certification Number: Expiration Date: � <br />�.. �(for work on homes thaf were constructed prior to 1978 <br />������ Phone: �' � 23 7 303 (office) (cell) � <br /> , Mailing Address: � 3 S . u,�, af Di City: dVt, � ZIP: �.�y °� <br />�� � <br /> Contact Person: �,L Applicant is: Contractor / Homeowner (Cirde One) .� <br /> Email and/or Fax: "� <br /> � <br /> ;:. <br /> PROPERTY OWNER INFORMATION: ;� <br /> Name: ✓G�t c� �P 1�,�%:, � � <br /> Phone (day): �j'S'oZ `�7.Z .�370 ;� <br /> Address: �7� �cs� �f <i�'� Cit <br /> - Y� D��J ZIP• <br /> Email and/or Fax <br /> � <br /> PROJECT INFORMATION: � <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel MCWD review& ermits: }� <br /> ❑ Fire Damage p � <br /> Minnehaha Creek Watershed District(MCWD) „,� <br /> Re-roof, as halt g 18202 Minnetonka Blvd 4� <br /> p ❑ Repair ❑ Storm Dama e <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 � <br /> ( p fy) ❑ Sidin Phone: 952-471-0590 <br /> , ❑ Re-roof, other s eci � <br /> } g ❑ Other. (specify) Fax: 952-471-0682 <br />`_' ❑Window(s) www.minnehahacreek.orq ''� <br /> .� <br />��' Overafl Project Description: F ' <br /> Estimated Construction Valuation of Project(excluding land) $ ���(f, � <br /> �;. <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 � <br /> }' are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative � <br /> but to reject it until it is complete; :x <br /> ;� <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 ;�� <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies �: <br /> re uired b law. If ou refuse t u I the information,the a lication ma not be issued. <br />�,°- , <br /> ApplicanYs Signature: / Date: ��� Z-`f /� <br /> Last Updated: 08-09-2011 ( � <br /> �,.. <br /> E;,�:. _ _ _ __ _ _ <br />