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City of Orono 11:,,- t-/ 9
<br /> , Building Permit Application for Maintenance / Renovation ,
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> 0,11 Cr Box 66
<br /> Crystal Bay, MN 55323-0066 Date�received:
<br /> 1
<br /> ‘CP:.°
<br /> .� � z s Street Address: Received bye
<br /> �� li �^�'r, o~ 2750 Kelley Parkway Plan rezilewfee
<br /> ty � Orono, MN 55356
<br /> kesi oe-
<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: / re (, ( j (d r 1,-.1 5-1 L L., „ 1
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o
<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: f///5 .e, (I) S//t z4.t J,')
<br /> State License # Sr- 631 57 47; Expiration Date:
<br /> Lead Certification Number: ___.... Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: 7263:3„y 7i-870o (office) (cell)
<br /> Mailing Address: s-/y5 �ndu s/e_,'„ / SL, 5,..4- - /o3 City: /../,:(7„ y-7,,, - ZIP: 5-535 l
<br /> Contact Person: 7c,,, )h / Applicant is: O -etor' / Homeowner (Circle One)
<br /> Email and/or Fax: 7,�2 & cul5-4 4 �o4,.., .!fin,-,. / 7V g -L/-> 7'- cci 0 0 c
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: / 4I (04—c,c
<br /> Phone(day): C, i Z-P-5- 5 a- '
<br /> Address: /�6- tip,/d A UA..7-t- f c,-.i City: v20 ZIP:
<br /> Email and/or Fax -7�3_. 1.,, 29-d-?-0o
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel E Fire Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof, asphalt ❑ Repair E Storm Damage 18202 Minnetonka Blvd
<br /> 'Re roof, cedar ❑ DamageDeephaven, MN 55391
<br /> ❑ Restoration Water
<br /> ❑ Re roof, other(specify) Phone: 952-471-0590
<br /> ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑ Window(s) www.minnehahacreek.orq
<br /> Overall Project Description: f it n�7t ca d,,r ,il/ s!,l (k(
<br /> Estimated Construction Valuation of Project (excluding land) $ ‘-,o/ 0„c.
<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 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 /> required by law. If you refus- t. ..p.l k ainformation,the application may not be issued.
<br /> Applicant's Signature: 'Pi Date: /`(tel ,Z r 54 �oi 7.
<br /> Last Updated: 08-09-2011
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