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<br /> City of Orono �
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<br /> r�,' � `' Building Permit Application for Maintenance / Renovation � i ����� �
<br />"�� (windows, doors, siding, re-roof, etc.) �
<br />� Mailing Address: �
<br />� ' ��,L,0 PO Box 66 Permit number: �
<br />�v:
<br /> �, / Crystal Bay, MN 55323-0066 Date received: �
<br /> " I(� �s �\� �
<br />�°' ';a 4 ���;:; �, Street Address: Received by:
<br />� ��� �� '� =''� ti 2750 Kelle Parkwa �
<br /> �'� , �, o- Y Y Plan review fee: ,
<br />� � �L��Ho�� Orono, MN 55356 ����
<br /> s�
<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 appfications will be returned. lease prinf) �
<br />� GENERAL INFORMATION: _. � J �U /�v �� , �� O f�� �, S �5�� �
<br /> � Job Site Address: ` �J �
<br /> i
<br /># ` Will this be a Parade of Homes, Remodelers Showcase Home or other Dis la Home?
<br /> �, p y ❑ Yes �'No �
<br /> If yes, a specia!event permit is required with Polrce Department and City Counci(approval 60 days prior to the event. Shuttle bus service will be
<br /> ' required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
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<br /> , CONTRACTOR/APPLICANT INFORMATION: '
<br /> �Y: Name: �� �s %v��r% �'.e-T-�i��C�o rs �h c . �
<br /> E� State License# G��; Expiration Date: �v/� �
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978 �
<br /> t,; Phone: ,�G��- �:S"� - o o�3 (office) ��Z-�Z�S--7�/� (cell) �
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<br /> Mailing Address: �'Q� ,C� �.j Gy � �,�� r�,t City:�l� ZIP: sS�/�-J �
<br /> ��� Contact Person: (�;s �,,,��� Applicant is: �� on rac / Homeowner �c���ie One) �
<br /> .�_� ��
<br />=�;<: Email and/or Fax: �,s ����L�Jg p�y,P�,�(.���a� �„� 7G -�!%�77�' �
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<br /> PROPERTY OWNER INF RMATION: �
<br /> Name: �i�a �� /�w��,,/ �
<br /> Phone(day): ��� - f/� - /D • �
<br /> Address: �� `;�6�J �� �� City: p�U-�-� ZIP: �T.�s� �
<br />���� Email and/or Fax �
<br /> :,
<br /> PROJECT INFORMATION: �
<br /> Type of Project: Any earth movement may require �
<br /> MCWD review& ermits:
<br /> ❑ D r(s) ❑ Remodel ❑ Fir .Damage p �
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> �e-roof, asphalt ❑ Re air � 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 />�k�'
<br /> ❑ Window(s) www.minnehahacreek.orq j
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<br /> � Overall Project Description: � -� r�, �
<br /> ly P M
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<br /> Estimated Construction Valuation of Project(excluding land) $ � �0 Z ,��
<br /> APPLICANT ACKNOWLEDGEMENT:
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<br /> • Agrees to provide all information required or requested by the Building Department;
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<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 /> e;
<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 ' formation is to annually update our records and records of other governmental agencies
<br /> re uired b law. If ou refuse to s I t information,the a lication ma not be issued. �
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<br /> �,-- 5---� �� ,-'
<br /> `` Applicant's Signature: Date: �
<br /> Last Updated: 08-09-2011
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