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. City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> O Mailing Address: Permit number: �Q� '"�p "��
<br /> PO Box 66 //
<br /> � � Crystal Bay, MN 55323-0066 Date received: �dr� �^ -��
<br /> Street Address: Received by:
<br /> � �` 2750 Kelle Parkwa
<br /> y�, G� Y Y Plan review fee:
<br /> ! �, Orono, MN 55356
<br /> �kESH�� �/ ¢ �V
<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` `��' � �:, , '� �, � " ^ .-t�3 °
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or ot er 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. Shuttle bus s ice 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 /> Name: `L�,'�i-i i,-j �1 fJ'; �-��t-i l i�t; i �v�
<br /> State License# �1,� �,� � � ��� Expiration Date: :;� Z �, �,
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) �� l Z, �Ll t,q ."i.,�3�-� (office) �;� ��.�j��,'S' ���� u`i
<br /> Mailing Address: � ,� c,�;., S�- ; City: � ;� � •� �r,,�� ZIP: ��;- ��
<br /> Contact Person: �,�,L�,���f,�; Applicant is: ontra tor / Homeowner �c�r�ie one�
<br /> Email and/or Fax: ;?.f,o:�k= c'.; k-�16-It,-ni.,`'�t�ac��;,� t i��.c. ��v�,
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: '��f�.-i�'vts 1,�:iJ�
<br /> Phone (day):
<br /> Address "vs ?� S�v�„����.,�'Va.�.�, `-.� CitY� �.,r..,�� c���t�� ZIP:
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall ro�ect descri tion:
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> Re-roof, cedar ❑ Restoration ❑ Water Damage Deephaven, MN 55391
<br /> ❑Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑ Window(s) www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ j� : �, J�J , ' ��
<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 h information, the a lication ma not be issued.
<br /> ApplicanYs Signature: Date: � ''{��� � i�-i
<br /> Owner's Signature: Date:
<br /> Last Updated:03/06/2013
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