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- - City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: �� �. 'iy <br /> O�,�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: Z � <br /> a ,�, ;r� �, Street Address: Received by: � <br /> �'�L t a`� �ti�' 2750 Kelley Parkway Plan review fee: �� <br /> �kESHOg'� Orono, MN 55356 '; <br /> 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 be returned. (Please print) <br /> GENERAL INFORMATION: , ' <br /> Job Site Address: ��� �/L/�/� y�il� �U�-� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No ,s <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 <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: x� <br /> Name: _ KoUr�n9�r� ��r1cQ21''S , ����.. �' <br /> State License# �o� Expiration Date: � <br /> Lead Certification Number: �.,' �- Expiration Date: <br /> (for work on homes that were constructed prior to 1978 ;�� <br /> Phone: �5)- Z¢ - ��� (office) (cell) �� <br /> Mailing Address: � �,p�,E a� City: • ZIP: �� <br /> ,�t+ � k5 S S Z7 . <br /> Contact Person: (��-C� �����-E��E2 Applicant is: nntrac� / Homeowner (Circle One) `'�; <br /> ��: <br /> Email and/or Fax: ������,���� �� � <br /> PROPERTY OWNER INFORMATION: � Y, <br /> Name: ��L� �A��vrS.� � <br /> Phone (day): �jSZ- ¢73 � "7Z�d 1 �� <br /> Address: -7(�� 5�p�I�� (-�-, �� �a,�.p City: F'-j�p,�}p ZIP: SS�L� '� <br /> Email and/or Fax �f� <br /> PROJECT INFORMATION: " <br /> Type of Project: Any earth movement may require � <br /> ❑ Door(s) ❑ Remodel MCWD review&permits: "� <br /> ❑ Fire Damage <br /> Minnehaha Creek Watershed District(MCWD) ``� <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd � <br /> ❑ Re-roof, cedar ❑ Restoration Deephaven, MN 55391 ';-� <br /> ❑Water Damage ;,;� <br /> Phone: 952-471-0590 � <br /> ❑ Re-roof,other(specify) �Siding ❑ Other: (specify) Fax: 952-471-0682 :� <br /> ❑Window(s) www.minnehahacreek.orq -� <br /> ,� <br /> � <br /> Overall Project Description: " � Z � S,p,K- �,��cN"{-�le. 1= �ilh a <br /> Estimated Construction Valuation of Project(excluding land) �E.; RE-5,�(�, <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 5`� <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative '-� <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 <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 inform tion is to annually u our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I e inform ' ca on ma not be issued. <br /> � <br /> ApplicanYs Signature: Date: �Z�ZOI� '� <br /> Last Updated: 08-09-2011 ;�� <br /> '4� <br />