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<br /> ,�, City of Orono � � � �
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<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: �Permit number. c�% 1j — GG�( '�f �
<br /> O�,L,�,j�O PO Box 66 �
<br /> Crystal Bay, MN 55323-0066 Date received: .� ��-_/� ;
<br /> I a �� �, '� Street Address: Received by: "�
<br /> �`;';�
<br /> �'.�c� �� �ti 2750 Kelley Parkway Plan review fee: ��
<br /> L�kESH��'� Orono, MN 55356 ,;+ �
<br /> Total Fee: �� ��f'� ;�
<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: ,
<br /> �� � �
<br /> Job Site Address: ` .�' -
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o �
<br /> If yes,a specia/event permif 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 sufficient on-site parking is available. Non-permitted events wil!not be allowed. �
<br /> �
<br /> CONTRACTOR/APPLICANT INFORMATION: �
<br /> Name: �-..�t. \�_l-__�� '\ _
<br /> � State License# �l ii? Expiration Date: ��' ,J} �
<br /> Lead Certification Number: i„',�'• Expiration Date: r�f �� �
<br /> (for work on homes t�t were constructed prior to 9978 '�
<br /> Phone: C.%i� �' `!1 Li :'C,�_ _/ (office) (cell) �
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<br /> Mailing Address: � 7(` � � ,�� � City: ,�.�,:, � _ _ IP: ;� � >U� �
<br /> Contact Persorr: ��,,,�� Applicant is: Contractor / Homeownel� (Circle One)
<br /> Email and/or Fax: c��_{� �� �,� � �� c��.,�� �„ ,,�,� `.
<br /> � ,�
<br /> PROPERTY OWNER INFORMATION: �
<br /> Name: ,. . G ,1
<br /> ., , _. :
<br /> ,__ � �_. . ;- _ ,`'
<br /> Phone (day): �. �2- `� i� i G;. .7
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<br /> Address: '7_ �71`Z- 5����,,-, "� City: i�� �,�,J' ZIP: `� � 3c; '�
<br /> Email and/or Fax A-_
<br /> 11��- `��-,`�� C�- �i �--�ta�.i . c��
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<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br />{ ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review& permits:
<br /> ❑ Re-roof, asphalt ❑ Re air Minnehaha Creek Watershed District(MCWD)
<br /> p ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> ❑ Re-roof,other s eci Phone: 952-471-0590
<br /> ( p fy) ❑ Siding �Other: (specify) Fax: 952-471-0682
<br /> �l{1�lindow(s) �'1<� www.minnehahacreek.orq
<br /> Overall Project Description: �- . ;� ,� , �. �,:; �, ,� � _ ; ;
<br /> Estimated Construction Valuation of Project(excluding land) $ ���`. ,� �
<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 complete 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 all of the information that you are asked to provide on this application is classified by State law as either private or
<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 info ation,the a lication ma not be issued.
<br /> Applicant's Signature: � ( ��� ' ''� �/2"��
<br /> -�� �-'� Date: � � 1 3
<br /> Last Updated: 08-09-2011
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