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,�,� City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY
<br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION)
<br /> ���� Mailing Address: Permit number: "�C���k�� ���_3 ��
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-006 Date received: 1 L,- Z �r- l�,
<br /> Received b "�I�
<br /> Street Address: l� Y� �-�
<br /> y�, � 2750 Kelley Parkway ��� Plan review fee: � �;, l��� �� y�j
<br /> � Orono, MN 55356 � �
<br /> lqkESHO�� �
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �i�
<br /> This application form must be completed in full and all required information must be su mitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: � c> ( (; � , , �
<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. Shutt/e bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> �
<br /> Name: -
<br /> �ir' c � �� ��-�� ��+'lc.{.��,�1�-c,
<br /> State License# (;� � �j���� " Expiration Date: ; � Z
<br /> Lead Certification Number: �/,� j .....��, �C���, - Z Expiration Date: ,
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) ��Z- SZ,,�_ �y�� (office) --
<br /> Mailing Address: z �� �,,,,� �,�, � City: ��,, ,,,� ZIP: �y�,�
<br /> Contact Person: ��,� S,�t�� Applicant is:� Contracto`r / Homeowner (CircleOne)
<br /> _ ,
<br /> Email and/or Fax: ------- -
<br /> h�_-�l,.��. . «..,��1 S<;,.,� �z rt.s,.t��,��,�4 ,�: :...
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<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ����, ,��/,�� �� R�.-�1-�,,,
<br /> Phone(day): `/'S� - 737- �3Zu
<br /> Address: >o/G 5����, �-r..� I�� . City: ��..,,,�., �1� ZIP: JS-�S-l�:
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall pro'ect description: ���'`�����'��=�'L'E'��� �����'''�
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) [�Remodel ❑ Fire Damage MCWD review 8 permits:
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd
<br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345
<br /> ❑ Re-roof,other(specify) ❑Siding ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.ora
<br /> Estimated Construction Valuation of Project (excluding land) $_ �,��t,�,c--
<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 /> • 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 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 annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I the information,the a lication ma not be issued.
<br /> �._.
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<br /> ApplicanYs Signature: ' �.-- " =�" Date: /��� (�,
<br />, Owner's Signature: Date:
<br /> �, /
<br /> Last Updated:January 2016 ��'G/L� `����%� /��� ' �
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