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���Q . <br /> City of Orono � <br /> Bui�ding Permit Appiication for Maintenance / F ��7� ration <br /> (No structural expansion. Onfy windows, door �.f� ��6 ��7i I <br /> Maiting Address: c! '/as <br /> �D�TO PO Box 66 �3`��-0 <br /> Crystai Bay, MN 55323-0066 � <br /> Street Address: Received by: <br /> y� 1 `� 2750 Kelley Parkway Plan review fee: <br /> �,� Orono, MN 55356 <br /> ��KESHO� Total Fee: � ���' �5 <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 information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: -� ` ' l ��� �j 3 <br /> Job Site Address: � �.�t��� �Y"�C�`��6v��. �v�lU(? L �Ct-�ZC��I � , � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Dispfay Home? ❑ Yes No <br /> If yes, a special event permit is required with Police Department and Ciry Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR!APPL CANT INFORMATION: <br /> Name: � `1�� Gl� �l�'Y�L� S -�-1�C'- ._ <br /> State License# _���cj c� � Expiration Date: � ' <br /> t <br /> Lead Cer�ification Number: Expiration Date: <br /> (for work on homes that were constructed pr,i�Qr to 197� f�---�_ �� a � �� c-�-7 � <br /> Phone: (cell) � ,� � �,� ��(`�d � (office� <br /> Maifing Address: ` � � �3 City: � ' 1 ZIP: J�,3��1 <br /> Contact Person: ���,}Q� � ��j ,�jL.(�J� �'1'"1 Applicant is: Contract / Homeowner (Circle One) <br /> Email and/or Fax: ���(t�� i Ss�'/'� � �77 �l�Q � rY�C' I �c��-� <br /> � <br /> PROPERTY OWN INFORMATION� � <br /> Name: ��C�� �' l��i <br /> Phone (daY): J �'��7- ) <br /> Address: � . �t IYl e� •�,�, City: /y ���, ZIP: ��,� �`��%/ <br /> Email and/or Fax: <br /> ��st-�� �rn.� - /�s�yr�.��-E-�rn -:1"-�5cc�df��►� �urtd�zfi�✓� l�� <br /> PROJECT INFORMATION: Overall pro�ect descnption: <br /> Type of Project: Any earth movement may also require f" <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: L�G/L <br /> ❑ Re-roof,asphalt �,.'Repair�n��� . ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) r�P� <br /> � � 18202 Minnetonka Bfvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �n� <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excfuding fand) $ �� �C'an <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a compfete application being aware that upon failure to do so, the staff has no alternafive but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is cfassified by State faw as either private or <br /> confidential. Private data is information which generally cannot be given to the pub(ic but can be given to the subject of the data. <br /> Confidential data is information 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 annualfy update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the' f ation,the a ic,ation ma nat,be issued. <br /> AppficanYs Signature: � G��� � .E�� Date: t�.��%�'j�.�[�i�� � <br /> �z ��- ��� /�- �'�'��`'����1�`e`'��-<<____� <br /> Owner's Signature: a e: <br /> Last Updated: 03/06/2013 <br />