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MAY/02/2012/WED 05; 16 PM Fax Ser�er FAX No, P, DO1/001
<br /> ,
<br /> City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number: ' -`� '� �� j �
<br /> O��,j�.O PO Box 66
<br /> Crystal Bay,MN 55323-0066 Date received:
<br /> � �, Street Address: Received by: .
<br /> �,�, � �titi 2750 Kelley Parkway Plan review fee:
<br /> �ESH�¢'� Orono, MN 55356 -,�
<br /> Total Fee: / �t � �-=
<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 infoRnation must be submitted.
<br /> Incomplete applications will be returned. (P/ease print)
<br /> GENERAL INFORMATION:
<br /> JobSiteAddress: '-{-� �0.d w� 2�c� ��c�-�z��-1 ►'�'� ,--� 5�3�'' 1
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o �
<br /> !f yes,a specia!event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service will be
<br /> _ required unless appllcant demonstrates sufficient on-sife parking is available. Non-permitted events wlll not be a/lowed
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �rA.�,, lo� �rcxlc, C..O�'j�ar� o�-, .
<br /> State License# ��ii� �(U\r1 (��,�-�S p'1�j Expiration Date: N�c�,��,(,l 3� �.��3
<br /> Lead Certification Number: �p.-r_ �d S�Z 3_� Expiration Date: M�,�-.�., �� � �zo t Co
<br /> (for work on homes fhat were constructed prior to 1978
<br /> Phone: q S 2 . B a Q, _ Z�o (office) {cell)
<br /> Mailing Address: ,,�,� � � City:�'ccleri(�rc�,;r;�e ZIP; �5 3
<br /> ContactPerson: ��,��,��� �b�.��„-� Applicantis: ontractor / Homeowner (CircleOne)
<br /> Email and/or Fax: �,5�,- a 3 R . �I-c�o 0
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: '���r�,� ��n,n
<br /> Phone(day): G5�• y `l l • �o� 3 Oro��
<br /> ' Address: t o �y-,�,� a � City: � ZIP: -- �3 �
<br /> Email and/or Fax � �. '��s no� hc�.�c �rna-�.� or .�o...�.
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ��roof,asphalt ❑ Repair ❑ Storm 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) www.minnehahacreek.ora
<br /> Overall Project Description: �{,.�,-,-,o�,� �¢.dc�c �('oo�" +�2c.�1�c�.. ,,,��-'� �s.o� r oo F
<br /> Estimated Construction Valuation of Project(excluding land) $ �3�eoc� . O�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifles that the informatlon 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;
<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 to su I the information,the a lication ma not be issued.
<br /> ApplicanYs Signature: ��v2..� C�y���o-,..� Date: �C�- 1/�
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