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<br /> • City of Orono � �" `� ���
<br /> $a�, � �:
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<br /> Building Permit App(ication for Maintenance / Renovation
<br />�,Y� (windows, doors, siding, re-roof, etc.)
<br /> f�" Mailing Address: Permit number.
<br /> �v 0,� PO Box 66
<br />��' Crystal Bay, MN 55323-0066 Date received:
<br />;= 0,�., �
<br /> a ' �y-�' s, Street Address: Received by:
<br /> � �.1�-
<br /> : � Gti 2750 Kelley Parkway Plan review fee:
<br />,� �'�.kESHo�`� Orono, MN 55356
<br /> : Total Fee:
<br /> w;` 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: *
<br /> d � �
<br />�'�� Job Site Address: � ��-� �p��� �,'�9� �� �,�� U �.� ��� ;�
<br /> �, Wilt this be a Parade of Homes, Remodeiers Showcase Home or o her Dis ay Home? Yes ❑ No �
<br /> � If yes, a special event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service will be �'
<br /> required unless applicant demonstrates suffrcienf on-site parking is available. Non-permifted events will not be allowed. ;�
<br /> � CONTRACTOR/APPLICANT INFORMATION: ��'
<br />��,` Name: � 2�Ci �� � 1 (Z.� � �
<br />��� State License # � �j J Expiration Date: '�
<br /> £.
<br /> �' Lead Certification Number: Expiration Date: � ._ � � — �'�
<br /> ' (for work on homes that were constructed prior fo 9978
<br />��;i Phone: (office) /'z — 2 2 / _ � /2S (cell}
<br /> Mailing Address: � Z�f3 ; � City: ��� ZIP: js �
<br />�-�_; Contact Person: S. �� �y�,, . Applicant is: Contractor / Homeowner (Circle One)
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<br />� ' Email and/or Fax: — , � ,��, ,. ��Q�
<br /> c� �PROPERTY OWNER INFORMATION: ;��
<br />�,.ti Name: ��11.9 i 1�1 �--, �A�'�� �-_
<br /> � �
<br /> �`� Phone(day): -
<br />� ' ,
<br />��? Address: ( �p� ���� � ���� D1� City: ( Q y��� ZIP: �
<br />�' Email and/or Fax �
<br />� �
<br />��;�: PROJECT INFORMATION:
<br /> t �
<br /> k T e of Pro'ect: �"
<br /> YP J Any earth movement may require ��
<br /> MCWD review& ermits:
<br /> ❑ Fire Damage �;
<br /> a ±Y Door(s) ❑ Remodel Minnehaha Creek Watersh d District(MCWD)
<br /> �Re-roof, asphalt ❑ Re air `
<br />��.; p ❑ Storm Damage 18202 Minnetonka Blvd r.;�;
<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 �u
<br /> t ' �
<br />�`s' ❑Window(s) www.minnehahacreek.orq �
<br />�� �'�
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<br /> °, Overall Project Description: �
<br /> �,
<br />��= � ���c� �
<br /> ��. Estimated Construction Valuation of Project(excluding land) $ ra
<br /> �
<br /> r "' APPLICANT ACKNOWLEDGEMENT: �
<br />�,., �
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> x�
<br /> �
<br /> ��
<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 complete application being aware that upon failure to do so, the staff has no alternafive
<br /> �3
<br /> but to reject it until it is complete; �
<br />'�;' ;
<br />�,�; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or �;i
<br /> �' confidential. Private data is information which generally cannot be given to 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 I the i_Rfocct�atior�the a lication ma not be issued. ;�
<br />���; ; �. �
<br /> ApplicanYs Signature: '" % �'� � Date: �
<br />�; ;. s-��� -/z.
<br /> Last Updated: 08-09-2011 �
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