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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> windows, doors, siding, re-roof, etc, <br /> eo <br /> O� Mailing <br /> Box as Address' • ank number: D/!* -Da 9 <br /> Vol" Crystal Bay, MN 55323-0066 .pp rem : <br /> &metAddmss; RecelVed by:. <br /> 2750 Kelley Parkway . Piet1•reviewflse: <br /> Orono,MN 56358 <br /> Main: 062-248-4800 Fax: 962-249.4010 i ono. us Tntai Fee: <br /> Thls application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION- <br /> Incomplete applications will be returned. (Please print) <br /> Job Site Address; ono 6 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> 11Yft a specki event penin!to required with Polka Depkrhnenf and OQy Council approval eo days p <br /> roqulred unless appNCknt d Mmsfratea huff ant on,s/to park/ng is @VWMble, rior to the avant Shulfk bus aeroh:e MY beCONTN <br /> onpermrfled evkgra will nor be allowed. <br /> Name:1�CTOR/APPS N�INPOR�fiAATlp�l: <br /> A L,! Or <br /> State License# Expiration Date: <br /> Lead Certification Number Expiration Date: <br /> (for work on homes that weak coneftetrd prior re 1871 <br /> Phone: – 77v qj( (office) celq <br /> Mailing Address: L( tt N4. je 1 V CI ZIP: N, <br /> Contact Person: G �O `1 <br /> Applicant is: (Contractor / Homeowner Icims one) <br /> Email and/or Fax: h,, L, k-VI-IJ <br /> /"IV,L•o A, r`S - 7 7 e> U( <br /> PROPERTY OWNER INF RMTION: <br /> Name: ,, <br /> Phone(day); 3� <br /> Address: <br /> Email and/or Fax Clly: 6 D a zip: <br /> PROJECT INFORMATION: <br /> Type of ProjW: ' <br /> Any earth movement may require <br /> ❑Door(s) - []Remodel ❑Fire Damage MWD review a permits: <br /> ❑Re-roof,asphalt 11 Repair Storm Damage Minnehshe Creek Watershed Dlstrict(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 56391 <br /> ❑Re-roof,other(spec fy) ❑Siding ❑Other, (specify) PFaxe•952-47- 600 <br /> ndow(s) Mmm-Minnahahumak, <br /> Overall Project Descri on: <br /> Estimated Construction Valu ati n of P eat excluding land) k l <br /> k4 I <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 hialher 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 aitemative <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 /> u)red by law, if Vou refuse to supciv the inform ion ths OPPIleation may not be issued. <br /> Applicant's Signature: <br /> Date: <br /> Leal Updated: 08-09.2011 <br /> X<dd 1317213Std-1 dH Wdl* : i 2102 21 deS <br />