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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> MaNing Address: <br /> 'g►0, PO Box 66 Permit number_ -� <br /> Q Crystal Bay,MN 55323-0066 Date received: - <br /> Street Address: Received by: <br /> 2750 Kelley Parkway <br /> off$' Orono. MN 55356 Plan review fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 MM-ci Orono rn us Total Fee. Iq'q'D,& <br /> This application form must be completed in full and all required informmust be submitted. <br /> GENERAL INFORMATION; <br /> incomplete applications will be returned. (Please print) <br /> ^ Q,` S <br /> Job 31te Address: p( ��( Lo <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Ll Yes U No <br /> M yea,a specie/event permit/a required with PON"Department and City Council approve/ao days wfor to the event. Shuffle bus seMos will be <br /> requited unless applicant demonstrates suRhclent an-aIle parking/s avomble. Non-pem~9vents wN/not be eNowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Nam®: 1 '111 �+l iar�{rSe�rV <br /> State License# 5C-1,609157B Expiration Date: 'y/31 <br /> Lead Certification Number: 00 AIT_ a'}a S 3 -1 Expiration Date: 3115 <br /> (tor wank on homes that were aonsftated pdw to 1978 <br /> Phone: _ (c5 - a(Ot`-4'+-+-+ (office) (09111Mailing Address: 1 •• •• We,%+ City; ZIP: S <br /> Contact Person: <br /> Email and/or Fax: Applicant is: / Homeowner (mme one) <br /> PROPERTY.OWNER INFORMATION: <br /> Name: ` <br /> Phone (day): �".I _ <br /> Address: CS; City: ZIP: <br /> 9LODO= <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: <br /> Doors) ❑Remodel �rMCIND review&earth movernent mrmits ulna <br /> ❑ Fire Damage Minnehahe Creek Watershed District(MCWD) <br /> Re-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,ceder ❑Restoration ❑ Water Damage Deephaven, MN 55391 <br /> ❑Re-roof,other(sp&cW) ❑Siding ❑Other. (specify) PFax: 952.471-06820 <br /> Windows)boor wniw.minnehahacreek oro <br /> Overall Pro ct Description. <br /> Estimated Construction Valuation of Project(excluding land S <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 albemative <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 date 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 ageneses <br /> required b law. If u refuse to su I the information thea lication mW not be issued. <br /> Aoolicant's Sionature:h4A-4�4401r- � Date: l�SeP-tl c7- <br /> 2 -d 061911►L9199 33IA83S 1IW83d a B S M L0 :01 ET02 ST daS <br />