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,, City of Orono � �
<br /> . Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> / Mailing Address: Permit number: �_� ' �UC��q
<br /> /.��,�. PO Box 66
<br /> Q Q Crystal Bay, MN 55323-0066 Date received: �c��.
<br /> 'z � � a�
<br /> ,� �; ��� �, Street Address:
<br /> ,,, ti
<br /> '�, > �ti 2750 Kelley Parkway �--
<br /> l.ykE$x� Orono, MN 55356 -
<br /> ��=_� Total Fee: '
<br /> Main: 952-249-4600 Fax: 952-249-4616 vw✓w.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: / �p ,Q,L�f r' ,; �;f ��( �7�
<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 Cify Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicanY demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �v,�nt±��'"tc�ti-�-L .1nc�.�7'�i'�t5 ,�nL :
<br /> - �
<br /> State License# �,,,�y,�L{ Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: C�c�Z� ZZIv -S 3�1 y (office) (cell)
<br /> Mailing Address: Pp B�.z 37 ��� s��,- �•vt�v 5 5 3 3 � �+P--
<br /> Contact Person: -r,�,, L��L�-�- Applicant is: ontractor '/ Homeowner (Circle One)
<br /> Email and/or Fax: G 5 � ya„i�{s���;,� � y�t,o� , ��:�
<br /> T�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: G�ati��Le. w�.��L l��lo�,,-c�L. T-�oCa-�
<br /> Phone(day): l- �lo�l- ,5"iZ_t�y33
<br /> Address: �3 7 0 ��z S f' ��vr�' (a,- CitY�,'VIo:,v�a� ZI P: Ss'3 �-(
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof,asphalt ❑ Repair ❑Storrn Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) ❑Siding �Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) � K -u� ��minnehahacreek.orq
<br /> Overall Project Description: 1�,�t�// ,,�, . r �t k,� cwro( �t,r � 17 ,`,,, � ,
<br /> Estimated Construction Valuation of Project(excluding land) $ � � poc�,�o �- Zo,coc�,�c�
<br /> APPLICANT ACKNOWLEDGEMENT: ��CP�v�
<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 hislher 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 altemative
<br /> but to 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
<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 govemmental agencies
<br /> re uired b law. If ou refuse u I the information,the a lication ma not be issued.
<br /> Applicant's Signature: e� �Ac,� Date: . $-i �— � I
<br /> Last Updated: OS-09-2011 .�_���C :�2,.
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