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City of Orono
<br /> B!ailding Permit Application for Maintenance / Replacement / Remodel
<br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION)
<br /> �O A Mailing Address: Permit number:
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> 1.
<br /> Street Address: Received by:
<br /> G` 2750 Kelley Parkway Plan review fee:
<br /> ,4,\IIIL
<br /> Orono, MN 55356�k@SHO�- 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: / 8 z LOi-fzi.2SY TizA-I L
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes [44No
<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/API ICANT INFORMATION:
<br /> Name: --J urs) / tCM.c_ 1)3fl- (4.04,rxw1 60;`oi—S
<br /> State License# 13L2-34-(z,7 Expiration Date: ','3ii� l�,
<br /> Lead Certification Number: i— i/7 z 4-7 -% Expiration Date: io/1 / zo l
<br /> (for work on homes that were constructed prior to 1978 / �
<br /> Phone: (cell) (office) lA('off o2 2 //g0
<br /> Mailing Address: qeicic/ 30774 ST S. City:4,„4.e0 L A-1i_-_ ZIP: S-S3 4--
<br /> Contact Person: LSL. -SLA.uL ,.,D Applicant is: toi / Homeowner (Circle One)
<br /> Email and/or Fax: 1.....6_a_ Q —t-1%v 1,i Keric.)1,1.Ip�i` 1 G(t✓'S , lk-4.:—
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: s`T£ us: -LAV LAJA,D
<br /> Phone(day): ( S--2_- ( r3 - 12)0'3
<br /> Address: 5 7_-i.,, t t t 3-c-1. S-r- t,.r City: r Lx,�.-.....,, -r-r.,,„ZIP: .f —
<br /> Email and/or Fax: S3..4 1-1,_t_,.,,,.,c_k,�s,.vt�,cL , con‘
<br /> PROJECT INFORMATION: Overall project description: Cc1LF i wD .c-,,z rZ -eab
<br /> Type of Project: Any earth movement may also require
<br /> MCWD review&permits:
<br /> ❑ Door(s) Remodel IDFire Damage
<br /> 0 Re-roof,asphalt 1:1 Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 15320 Minnetonka Blvd
<br /> ❑ Re-roof,cedar 0 Restoration ❑Water Damage Minnetonka, MN 55345
<br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> 0 Window(s) www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project (excluding land) $ /be) Co U
<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 update our records and records of other governmental agencies required by law. If
<br /> you refuse to supply the inf. , atioi,t - application may not be issued. j
<br /> Applicant's Signature: Date: Zl i 4.1 5---
<br /> Owner's
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2015
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