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` City of Orono
<br /> ' Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number: ��t —�b 5
<br /> j�/�,0\ PO Box 66
<br /> \� � Crystal Bay, MN 55323-0066 Date received: 'a�P�
<br /> a ! ��,�_ � ��-- p
<br /> , ��, s,� StreetAddress: ceived _ T"
<br /> �'.F, ' '��`�' GtiF 2750 Kelley Parkway �� � Plan review fee: � 9. � /
<br /> L9kE3H��`� Orono, MN 55356 .� d /� — d,Z� �O �
<br /> �_--_= Total ee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us °' � j? � , �,h
<br /> This application form must be completed in full and all required information must be submitted. { n�;��j ��1�
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: ` �1 � ��� ' . ��c�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other 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 service 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,q vi'1 �c`��t�,l-t
<br /> State License# ? ��(d'7�f�L Expiration Date: ��J"3 I I7�1 3
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: �� J Z —�4f� — �'7"Z_� (o�ce) (cell)
<br /> Mailing Address: � ��,L3 �,,,,,a,�� (,�,,.� City: ti1-n n ZIP: '�j S ` L
<br /> Contact Person: ;� Applicant is: ontractor� / Homeowner (Circle One►
<br /> Email and/or Fax: �rj; , ( � ���� p��,�,p,y��� u��y�
<br /> PROPERTY OWNER INFORMATION: `
<br /> Name: �v SC.�YI C�n.GI c�i�S�,YI ��` r-�1
<br /> Phone (day):
<br /> Address: °2 Cj(� Svs�� �ip� CitY: Qi�'O►�-D ZIP: �3�1p
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<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 /> ❑Window(s) vwuw.minnehahacreek.orq
<br /> Overall Project Description: $c�d�,•-oc��,�� Gtre�( M,�t�;�r �oSe� 12,Q,vnooCGL
<br /> Estimated Construction Valuation of Project(excluding land) $ 2?5, pCx7,<`��>
<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
<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 /> • 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 refuse to su I the information,the a lication ma not be issued.
<br /> ApplicanYs Signature: "<z-�z-���—'�"z..,� Date: 4�Z � ��Z
<br /> �
<br /> Last Updated: 08-09-2011
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