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a�g, 9. 2016 3:49PM � No, 2900 P. 1
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<br /> C��y of Orono . .
<br /> Building Permit Appfication for Maintenance/ Replacement/ Remodel —.Resi�d;�nti:�;�;�ON�LY
<br /> (i.e, windows,do�rs, sidin�, re-roof,etc.�NO STRUCTURAL EXPANSlON) �
<br /> Mailin Address: .: _....�,:... ..::;_;.:.:::::__:.._ ';_�;:::�,�.�,;�3
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<br /> ��J' PO 8ox 66 : _ - _ - `;;�,:=,'=.:
<br /> � 5323-0066 :'Date'�e�ived:`�':'u;��"��';•::=,��"�'-'�:.
<br /> a Crystal Bay,MN 5 ,...�..,:-::�,.:..:, - .... ._,.._ ..:......:.,,• ::;,
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<br /> 5treelAddress� '-•;:__-�.=:_.;.:-y� ,�:�:� - -
<br /> "� � 2750 Kelley Parlcway ''Pran�[Qvj�w'.fe"�� - - - ' �
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<br /> G N 55356 -
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<br /> 952-249-4616 ' �::_•- ..=;�; _ _
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<br /> www.p.orono.mn.us •�:..m::.:.__... •;:,:.,. .:=:t,.-
<br /> Main: 952-249-4600 Fax: -::,.��:,-..,:--•..,_...�:._-.. _::...;:-�;��:-._� .�.,..._,,:..;<:...;�::::.:..
<br /> This application form m�st be completed in full and aU required informatlon must be submitted_
<br /> Incomplete applications will be returned. (Please prinf)
<br /> GEN�RAL INFORMA7I�N' �
<br /> dob Site Address: `
<br /> Will thls be a Parade of Homes,Remodelers ShoWcase Home or other bisplay Home? Yes No
<br /> • H yes,a speCal evenf perm/t rs�eqp�red with Pvtke Oepartmsnt and Clty Council approval 60 days prior to fha evenk ShutNe bus se�vlce wiJl be
<br /> requi►ed uMess applicant demonshafes su/Bcienf onsite parXing is avaP19D1e. Non-permltted evenis wid not be a!lowed.
<br /> CONTRACTOR 1 ApPLICANT 1NFORMATION:
<br /> Name: S[, v 2x S g
<br /> State Licanse# Expiration Date:
<br /> Lead CertJfication Number: �, F,cpiratlon Date:
<br /> {for work on homes that were construct�d prior�0 99y8 o�ce
<br /> Phone: (cell) O(�. � �
<br /> Mai{ing Address: �J Gity: ' 21P:
<br /> Contact Person: � Applicant is� ontract / Homeowner (Clrcle One)
<br /> Email and/or Fax: r
<br /> pROP�RTY OWNER IN�ORrM�-A�TION:
<br /> Name; � ) �I��' ��1 S�-'"`' ,
<br /> Phone{day): C�y. ZlP: J S
<br /> Address:
<br /> Email ahdlor�ax:
<br /> PROJ�GT IN�ORMATION: Overall pro ect descrl tion:
<br /> Type of Project: Any earth movement may also requl�e
<br /> INCWp review&permits:
<br /> ❑Door(s) ❑Remodel ❑Fire Damage
<br /> Storm Dama e ��nnehaha Creek Watershed pistrict(MCWD)
<br /> ❑Re-roof,asphalt 0 Ftepalr ❑ 9 1532o Minnetonka Bivd
<br /> []Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345
<br /> Phone: 952-471-0590
<br /> ❑Eie-roof,other(speci4y} ❑Siding ❑Other:(speciFy) ��: g52-471-0682
<br /> Window(s) .minneh creek.o
<br /> Estimated Construction'Valuation of Project(excluding land) $
<br /> APPI.ICANT ACKNOWI.EDGEMLNT:
<br /> . Agrees to provide all informa6on required or requested by the 6uilding Department;
<br /> . Certifies that the inFomtation supplied is true and correct to lhe best oP hisRler knowledge, The applicant recmgnizes that they are
<br /> solely responsible for submitting a complete application befng aware that upon failure to do so,the sta�f has no alternative but to
<br /> reject it untll it is complete;
<br /> . Some.or alf of the information thal you are asked to provide on this application is classified by SEate law as e9ther private or
<br /> confidenlial. Private data is informaUon which generally cannot be given to the public but can be given to the subject of the data.
<br /> Confidential data is information which generally cannot be given to e�ther the public or the subject of the data. Our purpose and
<br /> intended use of this information is to annualty update our records and records of other ove mental agencias requlred by law. If
<br /> ou refuse to su f the inf� ation Ih a lication ma not be issued.
<br /> Applicant's Signature� bate: �
<br /> Owner's Signature: Date:
<br /> 4ast Updatetl:January 2018
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