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JUL-23-2015 13:09 FROM:TREBILFOUNDATION SYS 3205938720 TO:19522494616 P. 1/2 <br /> a 4 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> h' <br /> Mailing Addmss:Box 66 Permit number: <br /> Q Crystal Bay, MN 55323-0066 Date received: — <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> - <br /> Orono, MN 55356 <br /> JVD <br /> Main: 952-249-4600 Fax- 952.2494616 www.ci.orono.mn.us Total Feer <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please pant) (� <br /> GENERAL INFORMATION' / <br /> Job Site Address: 17IW,4`L v✓�,c.�- /¢QL. � <br /> Will this be a Parade of Homes, R®modelers Showcase Home or other Display Homos Ll Yes No <br /> IF yes,a special event permit is required wO Poilce Department and City Council approval 80 days prior to the event. Shuttle bus service will be <br /> toquirbp unless applicant demonstrates sumclent on-Site par*fno is available. Non-permitted events will not be alto d. <br /> CONTRACTOR/A PLICANT INF RM TION: ;k- eQfe ce l a/� <br /> Nae. <br /> State License# Expiration Date: <br /> Lead Certification Number; Expiration Date: <br /> (for work on homes that were constructed pHor to 1978 <br /> Phone: cell) <br /> Mailing Address. City_ ZIP: <br /> Contact Person: Applicant is, ontracto / Homeowner (circle one) <br /> Email and/or Fax; <br /> COV <br /> PROPERTY OWN INFORMATiO <br /> Name" <br /> Phone(day), O <br /> Address: City; 402= Zip: �o <br /> Email and/or Fax -^ <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) Q Remodel 0 Fire Damage MCWD review a permits: <br /> Minnehahs Creek watershed District(MCWD) <br /> ❑ Re-roof,asphalt 110papair ❑Storm ournage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> Phone, 952-471-0590 <br /> ❑Re-roof,other(spoclfy) 0 Siding d Other: (specify) Fax: 952-4714682 <br /> ❑Window(s) www,minnehahacreek.org <br /> Overall Project Description: 1n1 <br /> Estimated Construction Valuation of Pro act(exclud gland) r wPc� <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 comploto 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 date 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 /> required by law. If ou refuse to supply the information the application may not be issued. <br /> Applicant's Signature: 171 <br /> "12Z Neg� Date: <br /> La$t UP08tod: 08-09-2011 <br />