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JRN-20-2017 11:46 FROM:TREBILFOUNDRTION SYS 3205938720 T0:19522494616 P.3/3 <br /> r ' <br /> City of Orono <br /> Building permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> OQ Ma,t,PO Boxr66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address.' Received by: <br /> a 2750 Kelley Parkway Plan review fee' <br /> Orono, MN 55356 <br /> ( _O �S <br /> Main, Total Fee: � <br /> 952-249-46b0 Fax: 952-249818 www.ci.orono.mn.,s,s lP <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) �� <br /> Job Site Address: Vtrr � <br /> Will this be a Parade of Homes. Remodelam Showcase Home or other Display Home? Yes <br /> if yes,a special event permit is requimd with Police Department and City Council approval 60 days prior to the event. Shuttb bus service will be <br /> required unless applicant demonstrates sutticient on-site parking is available. Non-pennitted events will not be allowed. <br /> CONTRACTOR t AP LICANT INFORMATION: <br /> Name: LewP �Q,c >rnrCJ l'r/�V <br /> State License �tl oration Date- <br /> Lead Certification Number: 0 Expiration Date: <br /> (Ior work on homes that were constructed prior to 1978 <br /> Phone: ;]p (office) <br /> (cell) <br /> Mailing Address: City. I-1k, QIP <br /> Contact Person: Applicant is: rac o / Homeowner (c,rc�s o�.i <br /> Email and/or Fax: '" (Z <br /> Con <br /> PROPERTY OWNER INFORMATION: <br /> Name- Id) <br /> Phone (day) 4r" <br /> Address; Ctty: zIP- �y <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may ropuiro <br /> 0 Door(s) ❑Remodel n Fire Damage MCWD review$permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> © <br /> Re,-roof,asphalt @pbir © Storm Damage 18202 Minnetonka Blvd <br /> Q Re-roof, cedar ❑ Restoration Ll Water Damage Deephaven, MN 55391 <br /> 962-471-05 <br /> C] Re-roof. other(specify) ❑ Siding a Other: (specify) Phone:Fax: 952-471-0682 <br /> Q Windows) www.minn AggL"k,orp <br /> Overall Project Destro tion: jA 9 1 - <br /> Estimated Construction Valuation of Project(excluding land <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, Confidontial 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 i8 to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to su Ply the information the application may not be issued- <br /> Applicant's Signature: JDate: <br /> Last Updated: 08-08-2011 <br />