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� ` RECEIVED <br /> Ci�y of Orono .�iu� 2 � Zo�� <br /> �uilding Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) C�N OF ORONO <br /> P✓lailing Address: �� r �� <br /> /�0,�\.� PO Box 66 Permit number: <br /> /Q , o\ Crystal Bay,1V1N 55323-0066 Date received- lO `� — <br /> � ��';'� -.- Received by_ <br /> ,.� U ,��;�,_, a.,� StreetAddress: <br /> ���`54 ti <br /> �'\�,p������ti 2750 Kelley Parkway Plan review <br /> �sk�s�o4 Orono,MN 55356 <br /> '�� Total Fee: Fi'D� �� <br /> Main: 952-249-4600 Fax: 952-249-4616 ww�v.ci.orono.mn.us �J � <br /> 7his application form must be completed in fulE and all required informatian musi be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL lNFORMATION: / <br /> Joh Site Address: �� �'j�C � <br /> Wifl fhis be a Parade o Homes, emodelers howcase Home or other DispEay Home? ❑Yes ❑ No <br /> If yes,a specia!evenf permit is required with Police Deparfinent and Crty Counci!approva160 days prior to fhe event. Shutfle 6us sefvice will 6e <br /> required unless applicanf demonstrates sufficfent on-site parking is available. Non-permiffed events wi!!not be a!lowed. <br /> CO�ITRAETOR/APFLICANT INFORMATION: <br /> Name: � �7`�,�� �_� �J'1G <br /> State License# � , ���� Expiration Date: ?�,�i� <br /> . <br /> Lead Certification Nurnber. �/��a�j.��s:� Expiration Date: S��-�� <br /> (for work an homes that�rere consfructed prfor to 1 S78 <br /> Phane: � � y� �5��� {of6ce) (cell) <br /> Mailing Address: � ��y,� Ciky�� � C ZIP: ���' <br /> Contact Person: L��� ,�5�-a-1 Applicant is: on Homeowner (Circie O e� <br /> Email and/or Fax: j��,f-�SG-'��/��jG1c.-� L��� �lZ�c; i��--�• Lf9�•Q j �6 <br /> PROPERTY OWNERj1�lEO/RMATIpH: � /� <br /> Name_ _�nl�i� �' � /�7:c �� <br /> Phone(day): <br /> Address: ��a�� City: ZIP: <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 8�permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> �-F�'e-roof,asphalt ❑Repair ❑Storm Damage 182Q2 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.minnehahacrsek.orq <br /> Overal{ Project Descrip#ion:�' �,�. �� c � 'c . ` � ,,� � <br /> Estimated Construction Valuation of Project(excluding and) � ��� �� ,e�� ��^��� <br /> APPLICANT ACKNOWLEDGEMENT: <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 his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a compfete 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 afl of the information that you are asked to provide an this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given fo 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 pl the inf mation,the a plication ma not be issusd. <br /> Applicant's Signature: � Date: �.% ��,� <br /> r <br /> Last Updated: 08-09-2011 ��rUJ <br /> .�a .ob i't��:� <br /> .�_____ <br /> j7J?.O� - <br />