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ti '" <br /> Ci�y of Orono <br /> 6uilding Permit Application for Maintenance 1 Replacement/ Remodel— Resider�tial ONLY <br /> iJ.�. Otit.�c,�"����, c��u��,s��a���, ,��-u��7, cf.�. - �9���'T��i:�o�����=:���������� <br /> ��A,. Mailing Address: ; /�; <br /> <y PO Box 66 Permit number: 'L%'�t(�"'^- <br /> 1 � � Crystaf Bay, N!N 55323-0066 Date received: �-- � � `(`� � <br /> I ----' <br /> + StreetAddress: Received by: <br /> ` 'y � 2750 Ke�ley Parkway Plan review fee: <br /> `�t �t'� Orono. MN 55356 <br /> R'r�'S ki Q4` <br /> Total Fee: � <br /> Main: 952-249�800 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form rr�usi be completed in ful!and ail required information must be submitte . � � <br /> Incompfete applications will be retumed. (Please printJ <br /> GENERAL INFORMATIQN: ! <br /> Job Site Address: f� 7� S�jR�V[,.�� ��c1 <br /> Will this be a Parade of Homes,Remodelers howcase Tme or oiher Display Home? Q Yes �Rto <br /> !f yes,a specia!evenf petmrf is required wdh Pof�ce Department and City Counc�7 approva160 days pnor fo the event. ShuRle bus servrce will be <br /> required unless applicani demonstrates su!frcient on-sife parking is ava�lable. Non-permitfed events wilJ not be al/owed. <br /> CONTRACTOR I QPPLICAIdT INFOF�,MA7101V: <br /> Name: /jl l�f'�--.Z/'��' <br /> State License# C Up �/�'� � Expiration Date: /-31� �f'/ <br /> Lead Certification Number: n/p r-���J��- � Expiration Date: �f� _�g <br /> (tor work on homes ihaf were constr�cted prior to 1978 <br /> Phone: (ce!#) �f�,'��r-�4,� (oifice}7G -SS 7- J���' <br /> Mai�ing Acldress: 7 z,S C�h'� Z�P� .5's3j <br /> Contact Person: / Applicant is- o ractor / Homeowner (CircleOne) <br /> Emailand/orFax: _S d <br /> PRAPEF2TY OWN�R IIVFORMATIOPI: <br /> t�ame: �oN f��e /l Y <br /> Phone(day): '�- y7l- 70� S„S�9 f <br /> Address: 70 S!�,4d�w� c�tyl�!'a+�-U ZI P: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Ove�all project description:9�e�+o+'e � � S, <br /> Type of Project: Any earth movem t may atso re ire <br /> ❑Door(s) ❑Rernodel ❑Fire Damage 'I MCINQ review 8 permits: <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> � 15320 fNinnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration 0 Water Damage Minnetonka,MN 55345 <br /> Q Re-roof,other�specify) �Siding ❑Other:(specity} Phone: 852-47'1-0590 <br /> _ _ _ . . . Fax� 952-47�-�682 <br /> _.. <br /> ❑Window{s) vr�nr.v.minnehahacreek.ora <br /> Estimatec�Construction Valuation of Project(excluding land) $ <br /> A�PLICANT ACKIdOWLEDGEMENT: <br /> _ ._ _ <br /> • Agrees to provide all inforrnation required or requested by the Building Depattment; <br /> . Certifies that the�nformation supplied is true and correct to the best of hislher knowledge. 7he ap�licant recognizes fhat they are <br /> solely responsible tor submitting a complete applica6on being aware that upon failure to do so,�he staf€has no aEter�ative bul lo <br /> reject it until it is complete; <br /> • Some or al9 of the inforrnation that you are asked to provide on this application is classified by State law as either private or <br /> confiderrtial. Private data is information which generally cannot be given io the public but can be given ta the sublect of the data. <br /> Confidentia�data is in(ormation which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annuaily update our records and records of ather govemmental agencies required by law. If <br /> ou reFuse lo su I the in#orrnatian.the a lication ma not be issued. <br /> ApplicanYs Signature:,,�.�� ��..�--• __ Date_ v ��7 ~`� <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br /> �•d e96�O1 96 LZ unf <br />