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<br /> , City of Orono
<br /> _ Building Permit Application for Maintenance / Renovation
<br />,�; � (windows, doors, siding, re-roof, etc.)
<br />�-� Mailing Address: Permit number:
<br />� ;
<br /> ��,�,�. PO Box 66 �
<br /> , Q � Q Crystal Bay, MN 55323-0066 Date received: .:
<br /> ' �"'- Received by: '
<br /> ,� � ��°-�?`_ �, Sfreef Address: ''
<br /> �,�, t �� �ti 2750 Kelley Parkway Plan review fee: �
<br />�✓' L`�hESHog� Orono, MN 55356
<br /> �' Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 vwuw.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: �`j Q �-�� � � ,���;� '� �,��o r`�/v° � x3 � �v �
<br />"' Will this be a Parade of Homes, Remodelers Show�ase H me or other Display Home? ❑ Yes No
<br /> If yes, a specral event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus se ice wifl be ,�
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> : ��
<br /> CONTRACTOR/APPLICANT INFORMATION�: f,a
<br /> Name: ��• /` s��� or.-i � � �
<br /> State License# � Ex iration Date: �
<br /> Z(�l0 1 7 4 4� p 3 3 I 1 Z. �
<br /> Lead Certification Number: Expiration Date: �
<br /> ;�;
<br /> x (for work on homes fhat were constructed prior to 1978
<br /> a;' Phone: (o � 2 - Z a'/- '7Ca `� 3 �office) q S 2 - � 7, - � S 5 �j (cell) }
<br /> Mailing Address: 3po d S'vn�c � I�ti�c� , S,vrc`n City: S��,^� �o,,�d�_ ZIP: � 5 3 � r ,
<br /> Contact Person: licant is: Cont ctor / Homeowner Circle One �
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<br /> Email and/or Fax: � �
<br /> y;;. � /Z ri:v/J/.�CLC v Pi -r"i� . L� ,;;�
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<br />,��` PROPERTY OWNER INFORMATION:
<br />,� Name: `�� I-•r, �� }- �
<br /> �
<br /> Phone (day): (4 ��� 2 •5 � 4 c�� d �
<br /> Address: 5$�^�'rv 6t3S 3R `d 12oa�� City:�� p�; � ZIP: � ; 3 � S�
<br /> Email and/or Fax ��
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<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 ❑Water Damage Deephaven, MN 55391 r�
<br /> Phone: 952-471-0590 ``�
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 ,;:�
<br /> ❑Window(s) www.minnehahacreek.ora
<br /> Overall Project Description: �'
<br /> Estimated Construction Valuation of Project(excluding land) $ (� U�p_ o � A�
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<br /> APPUCANT ACKNOWLEDGEMENT: �,,
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<br /> Agrees to provide all information required or requested by the Building Department; y''
<br /> ,x:'s
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they �'
<br /> ��
<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; :'�
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<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 ,F=��
<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 information,the a lication ma not be issued. ;�'�
<br /> �� � � � d �
<br /> ApplicanYs Signature: � � � Date: 9 Z ��� � �
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<br />„ � Last Updated: 08-09-2011 t,}
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