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City of Orono
<br /> ` Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number: o�Gi, o d
<br /> 0
<br /> �� Cr Box 66
<br /> _ Crystal Bay, MN 55323-0066 Date received:
<br /> 7/s. (•'A�'‘;� s, Street Address:
<br /> Received by:
<br /> �, �� ,� ', Gtiti 2750 Kelley Parkway Plan:review'fee:
<br /> t 1- Orono, MN 55356
<br /> 9ifESH04
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: ��
<br /> Job Site Address: Z9 t'D W c— Co- , C ',1 , 11 i0 SS-
<br /> 3 .5-4,Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes i51, No
<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: --c-1.,--,...,.. c
<br /> te-,S Yc f—t1-0 1-1 r/n
<br /> t vt.k S r •
<br /> State License # Zc7Sdlg 2-V-7 Expiration Date: 2 C/ L.
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: /S1- 30S i c/ 1 (office) 4a 2 6 -763,-3,-Zq`f�!
<br /> /1/S5(cell)
<br /> Mailing Address: , City: L, -d_ IP: // 7
<br /> Contact Person: ,,,r.1L �. �,,.-- ' Applicant is: 4. •ntract / Homeowner (Circle One)
<br /> Email and/or Fax: v ids/ 3qy r c.N Z
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: 'T;Ack .A 1"+16,-
<br /> Phone (day): CIS 1- 353- 417qi .
<br /> Address: 4-`f te wee v' r" City: Otto h 0 ZIP: J S'SS e
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ElRemodel I=1Fire Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> CI Re-roof, cedar illRestoration ❑Water Damage Deephaven, MN 55391
<br /> Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑ Window(s) wuwv.minnehahacreek.orq
<br /> Overall Project Description: 1 Tc,v-- ,C.� - c k Q Q\G C ,c
<br /> Estimated Construction Valuation of Project (excluding land) $ I 5; t) "2-
<br /> APPLICANT
<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. Confidential data is information which genpraity cannot be given to either the public or the subject of the data. Our
<br /> purpose and intended use of this informati. to annually update our records and records of other governmental agencies
<br /> required by law. If you refus t supply the • 'tion the application may not be issued.
<br /> Applicant's Signature: ,V I0,,,,,,44 Date: T--22.-'Z 01 t
<br /> Last Updated: 08-09-2011
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