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<br />� �f City of Orono � f -��
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<br />� b �.` �uilding Permit Application for Maintenance / Renovation �y�.r r.��;� ` �:
<br />�,' (windows, doors, siding, re-roof, etc.) �
<br />� Mailing Address: �,:�
<br />'" �,�,�. PO Box 66 Permit number: �
<br />, �, � Q Crystal Bay, MN 55323-0066 Date received: ��
<br />�' ��' `� r � Received by: }�
<br /> ��' a � � � �� F Street Address: �
<br /> �'.�c, � "'�'I� �,ti 2750 Kelley Parkway Plan review fee: ��
<br /> � Orono, MN 55356 �`
<br /> t`�kEsxos`''
<br /> �— Total Fee: '�y
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ;a�=�
<br /> This application form must be completed in full and all required information must be submitted. '.��
<br /> Incomplete applications will be returned. (P/ease print)
<br />�� GENERAL INFORMATION: �;
<br /> � Job Site Address: `� � �0 � .� /-� � n �}�'?� � �
<br /> 3 �� `l � .�1 JC_-� . �
<br />�� Will this be a Parade of Homes, Remodelers Sh case Home or other isplay Home? ❑ Yes ❑ No �`�'
<br /> If yes, a special event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shutfle bus service will be c�
<br />� required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. t_�
<br />� �
<br /> � CONTRACTOR/APPLICANT INFORMATION: �
<br /> E �,� 1 �
<br />�;,:; Name: fl . .; � d ��t C i- � v�, 5� �n.. � �;
<br />� State License # ��� � �� R C�5' Expiration Date: 3 �
<br />�' Lead Certification Number: Expiration Date:
<br />:;
<br /> (for work on homes that were constructed prior to 1978
<br />'�: Phone: � ( �, — (� g 5 — 4�g�' (office) � t �- ��5 — ��� � (cell)
<br />� Mailing Address: o� I � �`' U � l,z; c; 1c� ,C City:C�txv.ev� F'ea� (s ZIP: 5��[;c
<br /> Contact Person: �R'� �E Applicant is: ontracto / Homeowner (Cirde One) '�-��
<br />�. Da�� �t
<br /> �
<br />��, Email and/or Fax: � d � �'4
<br />�, ci.a.v . � ��c c_`, +,` �(�2��c,o � ; G 6 �.1
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<br />� ' PROPERTY OWNER INFORMATtON: ��
<br />� .�
<br />�.. Name: 5� ��,c d Lia � t� �,
<br />�k Phone (daY)� s� - — ! �'Z� ,
<br />�; Address: � l O O �ti - w � � C ; R City:�, _ �; ZIP: '`
<br />� Email and/or Fax
<br />��� PROJECT INFORMATION:
<br />�- ,,�
<br /> ;�. Type of Project: Any earth movement may require
<br />�,,; ❑ Door(s) ❑ Remodel MCWD review&permits: s�
<br /> ❑ Fire Damage ��
<br />� �; Minnehaha Creek Watershed District(MCWD)
<br /> �; �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br /> '' ❑ Re-roof, cedar Deephaven, MN 55391 ��
<br />,�� ❑ Restoration ❑Water Damage
<br /> ,: Phone: 952-471-0590
<br />��« ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 '��
<br />��; www.minnehahacreek.orq �'J
<br /> ❑Window(s)
<br /> _ �,t;
<br />��_' Overall Project Description: � �oa� ��
<br /> ��.
<br />�� Estimated Construction Valuation of Project(excluding land) $ � �, (,�'7� C, `� ��
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<br /> ' APPLICANT ACKNOWLEDGEMENT: E�
<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 n�
<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;
<br /> ��
<br /> f�'' • 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 enerall cannot be iven to the ublic but can be
<br /> .; 9 y g� p 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 /> 4 '
<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 to su I the infor tion,the a lication ma not be issued. �
<br />���
<br />"} ApplicanYs Signature: � � Date: CI (� �,.
<br />�,;
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<br /> Last Updated: 08-09-2011
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