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i ..;�'��'^"k�"= ��TMa�'„R'�`�'�� 7 � ; a .. ,C= m f a:.} : :� ; .. , t ' � �� # ".�' s C i ty of O ro n o �� '� �. :�� -��.�� ; Building Permit Application for Maintenance / Renovation :_ �,; (windows, doors, siding, re-roof, etc.) �; �`� Mailing Address: _ �� Permit number. �; �� PO Box 66 �; y Crystal Bay, MN 55323-0066 Date received: Id 5 �,�� a , � �f �, � Streef Address: Received by: �� '�� ti� 2750 Kelle Parkwa �� ��L , � p Y Y Plan review fee: i \kEs�og/ Orono, MN 55356 � � � . Total Fee: ��, �� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (P/ease print) = GENERAL INFORMATION: � �' Job Site Address: c�l0 7 �(.G��2r.�,�o�p 1.�� ;� �t' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No `� �>` 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 �, required unless applicant demonstrates sufficient on-site parking is avaifable. Non-permitted events will not be allowed. �' •,. . ___,� t�� �ON_TRA�/APPLICANT INFORMATION: E. -�- � Name: �GC$T;�` ��cJS�uctz-o— � State License# �p�3 is 7 SL Expiration Date: 3 3i ��- '� ; Lead Certification Number: � �� Expiration Date: � ?� 7��r,t'� � �" �' (for work on homes thaf were constructed prior to 1978 �,� E�' Phone: 7��- c-��'-/-S7oo (office) (cell) � $ ' Mailin Address: �3;� � �: 9 l S �it.A-r�s' �itz S City: (� ��,�/ ZIP: .� �k Contact Person: ��y� Applicant is: ontra or / Homeowner �c��ie o�e� � `�`` Email and/or Fax: {� �, , � 9 � ��' PROPERTY OWNER INF RMATION: 5,;. Name: l-ti�w rC.w.r � �v�,r �-6� ;� � Phone (day): (�y- g��- °g2�o�y '� �� Address: � (o-� �uS,r.nu,�� 'I�,� City: op2oa.,' r� ZIP: � �� � Email and/or Fax �� �.; � �; �� �; PROJECT INFORMATION: �' Type of Project: � Any earth movement may require �' ��' ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review &permits: '�'. Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd s: '�` Deephaven, MN 55391 ��i �, � Re-roof, cedar ❑ Restoration ❑Water Damage Phone: 952-471-0590 �� ❑ Re-roof, other(specify) ❑ Siding ( p fy) � , ❑ Other: s eci Fax: 952-471-0682 � www.minnehahacreek.orq � �"�� ❑Window(s) �;` Overall Project Description: �: �� Estimated Construction Valuation of Project(excluding land) $ .��,pp� ,-` �`� � APPLICANT ACKNOWLEDGEMENT: �" • Agrees to provide all information required or requested by the Building Department; � �`:� • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they � are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative ;� but to reject it until it is complete; � �� • 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;� � confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the �, �` data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our � ; purpose and intended use of this information is to annually update our records and records of other governmental agencies � re uired b law. If ou refuse I the information, the a lication ma not be issued. ,:�3 .;: � ApplicanYs Signature: � Date: �� J'� / I ' �� �- �.� Last Updated: 08-09-2011 a., �;