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Jan 15 13 05:25p Edgework Builders, nc. 612-368-3511 p.1
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<br /> Ci of Orono 322�
<br /> tY .
<br /> Building Permit Application for Maintenance 1 Renovation
<br /> (windows, doors, siding, re-roof, etc.}
<br /> /--� Mailrng Address: ' Permit numher: �/7��3 -�OT.3
<br /> //.e.,�,�.� �O Box 66
<br /> i.� y \ I rystal Bay, MN 55323-0066 Date receiwed: �"���.3
<br /> I�/O:a:i;�:Y-. O ,1�I ����II�J Received by:
<br /> (,� �`f�l,:� ,,� Stre t Address:
<br /> �',��; ;g� r,.-`�' �.�!
<br /> ��,�, ,. ,�� �ti� �ti�, �750 Kelle Parkway Plan review fee:
<br /> t ��'��'� w rono,MN 5356 ¢�
<br /> \�?s'EsAo4�� _y ��� ��
<br /> -- Toial Fee: o���
<br /> Main: 952-249-4600 Fax:; 952-249-4 16 ,�� c ���,�: !.:�.
<br /> This application form must e comple d in full and all required information must be submitted.
<br /> Incomplete applicatiuns will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: � 7 00 - �a
<br /> Will this be a Parade of Homes, Rerno elers S ase Home or other Display Home? Yes �No
<br /> If yes,a specia!eveni permit is reqvired wifh Jice Deparf�nt and City Council approva!60 days pnor to the event. Sl�uttfe bus service wi!!6e
<br /> required r�n/ess applicanf demonstr�tes su�cie on-s�te parking rs availabFe. Non-permihed events wil/no;6e alfowed _
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<br /> CON'�RA�1`OR/APPLtCA T IT�IFORMATI�I�: ' � �,,.. ';� „'�-, ' .
<br /> Name: �1� � �e(�.� i�C,
<br /> State License# � �� ;;= Expiration Date: 3 ��
<br /> L�ad Certification Number. � �- � ' Expiration Date:
<br /> (for work on homes fhat were constructed prior to 1978
<br /> Phone: (offi e) .- � ��� (cell)
<br /> -Mailing-Addr�ess: � �,� � • City: � ZIP: � - -
<br /> Contact Persorr: �� � Applicant is: C J Home�wner (Clrcle Qne► .
<br /> Email and/or Fax: �
<br /> �'ROPERTY OWNER 1NFORMATION:
<br /> R�ame: ' e.� 0✓1
<br /> Phone (day): � (
<br /> Address: - �o,, . City: .Ci9 ZIP:
<br /> Cmail andlor Fax � .
<br /> ��OJ��CT INFORMATION:
<br /> iype'tif�PfOject: �� � Any earth movement may require
<br /> � , ;I i i, �� _ MCWD review 8�permits:
<br /> ❑ I)oor.(s) 0 Remodel ❑ Fire �amage Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof,aspha�t �air ❑Storm Damage 18202 Minnetonka Blvd
<br /> O.Re'-Foofs cedar estoration ❑Water Damage Deephaven, MN 55391
<br /> . Phon e: 952-471-0590
<br /> �'Re-roof, other(specifyl [��.Siding_ ❑ Other: (sp�cify) Fax; 952-471-0682 ___
<br /> �. � _ . ;
<br /> ,,.. �
<br /> � , ❑Vlfi nd ow(s) - - - --- =--
<br /> Overal�;Project Descriptiorr. ` �.� t ' `"
<br /> �stimated Construction Valuation of Project (excluciing land) $
<br /> `;'t.
<br /> APPE.ICANT AGKNOWLEQGEMENT:
<br /> ;_-,.. � ,rAgrees to provide all information required or requested by the Building Department:
<br /> o Certifies that the information suppEied is true and correct to the best of his/her knowledge. The applicant recognizes thal they
<br /> �' a_;''?:�[� solely respon�ible�fqr submitting a complete applicafion being aware that upon failure to do so,the staff has no altemative
<br /> ;`�,, , but io reject it until it is complete;
<br /> . • - __
<br /> i�"'''+ - Scime or all of the^information that you are asked to provide on this application is classified by State law as ei#her private or
<br /> ��;,, � . �confidentiaL Arivate data is information which generally cannot be given to the public but c�n be given to the subject of ihe
<br /> data. Confidential=data�is=•information which generally cannot be given to eitfier the public or the subject of the data. Our
<br /> ���� -f'' ''''pui'{�ose and intended use of this informaiion is.to.annually ypdate our records and records_oF other government I agencies
<br /> re uired b law. If �u refuse to su 1 th info ati�n,the a lica#ion ma not be issued.
<br /> � " .:. ��� � � �� .
<br /> fi�plic�nt,s.Signature_ �- -� Date: , � `
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