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City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Remodel
<br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION)
<br /> �o V Mailing Address: Permit number: .2�s—(f�,2.�
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: �`,�
<br /> Street Address: Received by: /r/,e5;�--��
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<br /> 2750 Kelley Parkway Plan review fee: r cAal --- .•2
<br /> �e kESC.HO� G Orono, MN 55356 __
<br /> Total Fee: -- CV
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<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.usasolv, maxim rutooL
<br /> This application form must be completed in full and all required information m t-�s mitted. -
<br /> Incomplete applications will be returned. (Please prin 5 ,G(L' .)_ ,cial lS
<br /> GENERAL INFORMATION: � __%t'r`"`'i
<br /> Job Site Address: 6-7) C)x Fe.2-►, ',TZ0,4-z,j �j�,.., r e,
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ElNo
<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: .N9,22042_ -1t+N4\s 1...k-
<br /> State License# Pc 6.7g S'&.3 Expiration Date: 3._/._/6,
<br /> Lead Certification Number: n/AA JA-7-- F/23%-7(6, _ / Expiration Date: 47-/�-zc;t4,
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) 4,/2-7/p=171 I (office) q s-7.-9 i.. - 9/'3 0
<br /> Mailing Address: ?o 801,, 3-5 ► City: _,.„,,, ceL,r,=,,,. ZIP: ss--s
<br /> Contact Person: NATE G, Applicant is: •ntracto i / Homeowner (Circle One)
<br /> Email and/or Fax: ,14/e, r,�/eCt' „r60 lc,c.:,,,,sert
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: Sem IAI.AsM3u-tom
<br /> Phone (day): ( i'1— 8(9- .70-z e
<br /> Address: S'"?5 QK,F,.c-t" City: Out ro ZIP: ,5-5-35-(„
<br /> Email and/or Fax: Szct✓►, we \I. i ..sco. Guyv-‘
<br /> PROJECT INFORMATION: Overall project description: /add d Pcr`L r z �- '-� kx� - ,-.L e
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) model ❑ Fire Damage
<br /> MCWD review&permits:
<br /> o Re-roof, asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar 0 Restoration 0 Water Damage Deephaven, MN 55391
<br /> ❑Re-roof, other(specify) 0 Siding Other: (specify) rPhone: 952-471-0590
<br /> r Fax: 952-471-0682
<br /> 0 Window(s) www.minnehahacreek.org
<br /> Estimated Construction Valuation of Project (excluding land) $ '2y, sOc)`'li
<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 are
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to
<br /> 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 data.
<br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this information is to annually upda e o•r records and records of other governmental agencies required by law. If
<br /> ou refuse to su•.1 the inform- .0 wsoluiLn"..an ma_'not be issued.
<br /> Applicant's Signature: .15-.15Date: /ofis 2-c,t
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2015
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