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<br /> Cit of Orono '��� �,� {, .;
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<br /> : Bu�lding Permit Application for Maintenance / Replacement / Renovation #
<br />� (No structural expansion. Only windows, doors, siding, re-roof, etc.) `'
<br /> �O� Mailing Address: Permit number. al�I 3—d�`� �� `;
<br /> O PO Box 66 _ k`�
<br /> Crystal Bay, MN 55323-0066 Date received: ' �-3 ��
<br /> �1� �
<br /> Street Address: Received by: �v S Y,
<br /> '' y �� 2750 Kelley Parkway Plan review fee: �'
<br /> `�tq � �' Orono, MN 55356 ��/ _ 00�a �
<br /> � � 7
<br />.; kFSH° Total Fee: �
<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 f�e returned. (Please print) ;;�
<br /> GENERAL INFORMATION: �
<br /> Job Site Address: Z�,��`: j1r�-e��Z�L�t�t� �� - �J����'J� 55�� � �
<br /> S�;
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No �
<br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be ,X
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ;_�
<br /> �'�
<br />,�,; CONTRACTOR/APPLICANT INFORMATION: �
<br /> Name: .3C`.b'�-� G �;,,ti�,�2.- `f��1��A MA-�.Il�sG �!t'��=�-�`T �;
<br /> State License# L �' �" Ex iration Date: ' -3 ZG l`5 ��
<br /> � 3��: � .�� p� t - �
<br />` Lead Certification Number. �A i_l�-��{12 _ � Expiration Date: "�j�-c..( ^ 2,�� (o ;
<br /> (for work on homes that were constructed prior to 1978 ��
<br /> Phone: (cell) (p 12-��'- `�1�E, (office) �'
<br /> -� Mailin Address: ' ' � Cit : ZIP: �
<br />�, 9 y�7 � S�l7��c�c::� Q� - v M�'K-� 55 3`{ S
<br /> Contact Person: �� Applicant is: Contractor / Homeowner (CircleOne) �
<br /> Emailand/orFax: �,,��,�,,��tz �' •-f-�js�- M�/+ . t=M��-r- CnM �
<br /> ��
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<br /> PROPERTY OWNER INFORMATION: '.:�
<br /> Name: ���-�� ��l�l"�n-� �= � � ��
<br /> ;_�
<br />�;, Phone (day): �
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<br /> Address: 2�jS�.: �i�%� �-�-,.�� ? _ City: G�.e;r.�L; ZIP: >�j �`�j f �
<br /> r����� Email and/or Fax: ��
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<br /> PROJECT INFORMATION: Overall pro�ect description:�A-tt�l(--��n� �M���� ,�
<br /> Type of Project: Any earth movement may also require �
<br /> ❑ Door s MCWD review&permits:
<br /> ( ) �Remodel ❑ Fire Damage �
<br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) �f
<br /> 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 `�
<br /> ❑ Re-roof, other(specify) ❑ Sidin Phone: 952-471-0590 �
<br /> g ❑ Other: (specify) ,�
<br /> Fax: 952-471-0682 ,,,
<br /> f.< ❑Window(s) www.minnehahacreek.org
<br />..:�. -
<br />� Estimated Construction Valuation of Project(excluding land) $ 2 f��c�c� '�
<br /> �:,.,
<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 are �
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to ;
<br /> reject it until it is complete; �:
<br /> A,
<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 �+
<br /> j4 confidential. Private data is information 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 either the public or the subject of the data. Our purpose and ��
<br /> intended use of this inf ion is to annually update our records and records of other governmental agencies required by law. If ;�
<br /> ou refuse to su I e in rmatio . e+a lication ma not be issued. �
<br /> K Applicant's Signature:� � ��r -- Date: � ��� � � 1�
<br /> Owner's Signature: Date: �?E
<br /> Last Updated:03/06/2013
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