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.f�� .� ;�' . . � �� �� <br /> , �: <br /> City of Orono � <br /> + • Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: �Q�(_��0 � <br /> Permit number: <br /> �,0,�. PO Box 66 �/ � <br /> Crystal Bay, MN 55323-0066 Date received: / '��� <br /> � � � , <br /> ,� i � �, Street Address: Received by: � <br /> �',�, �`�i� Gti�' 2750 Kelley Parkway Plan review fee: <br /> t9'kESH�4� Orono, MN 55356 � <br /> � Total Fee: ���p, � ��, <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"v��0 S��(C� �L-i� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No � <br /> If yes, a specia/event permit is required with Police Department and City Council approval 60 days prior to the evenf. Shuttle bus service will be � <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. � <br /> -� <br /> CONTRACTOR APPLICANT INFORMAT ON: <br /> Nam . �S%1 '� �n,�°�c c c�-. � <br /> State License# ���3 �,��� Expiration Date: 3 3; i 7�— <br /> Lead Certification Number: f Ex iration Date: '� <br /> 1lI�kT' - <o �C $� � - i p� 7 �.t'" � <br /> (for work on homes fhat were consfructed prior to 1978 � <br /> Phone: �� - � _ ���a� (office) (cell) �::w� <br /> Mailing Address: �� � � � . S �-�L �¢- City: �.(.; Lc3-r ZIP: ��,�r m� <br /> Contact Person: ��� Applicant is: Contrac or` / Homeowner (Circle One) <br /> Email and/or Fax: �� <br /> � <br /> PROPERTY OWNER INFORMATION: t� <br /> Name: S/hv�,e�- G�.:.>�tc c.� ,� <br /> Phone (day): ; <br /> Address: /,�2-�� ��,tCL C� City:��2�'�;c„' ZIP: ��:3�,y" � <br /> Email and/or Fax `;r <br /> ;� <br /> PROJECT INFORMATION: � <br /> � <br /> Type of Project: Any earth movement may require � <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) � <br /> �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd � <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 '� <br /> www.minnehahacreek.orq � <br /> ❑Window(s) � <br /> Overall Project Description: �C;�Y�6L �v�r`` -- % ��%c*� �-� � <br /> Estimated Construction Valuation of Project(excluding land) $ '� pn � <br /> �� <br /> APPLICANT ACKNOWLEDGEMENT: �. <br /> ,:<x <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 /> ,r� <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 refu su I the information,the a lication ma not be issued. ;� <br /> ApplicanYs Signature: Date: � � � � "� <br /> .� <br /> Last Updated: 08-09-2011 �' <br /> _ _ <br /> � <br />