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f . City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address:
<br /> �,0,j1. PO Box 66 Permit�detrxtber: "7
<br /> Q
<br /> Crystal Bay, MN 55323 0066Date received:
<br /> , - ' ' -`,..V.V ,,,,p,, ,-;i,,-- --'.-
<br /> Received b
<br /> A a Street Address: y
<br /> 1,t,� t ,t;tiii r,- ,,c) 2750 Kelley Parkway Plan.a iew fee:
<br /> kESHo4 Orono, MN 55356
<br /> Total=Fee
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ' i
<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: ) P5 1Z,--d-v,�7' /,/P��
<br /> ,/ _
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ 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: /9j/ S�hz/c' C �, /' e" _/-' c) ey
<br /> State License# /5 G 6, 3/.5-_//.V Expiration Date:
<br /> Lead Certification Number/, 22 752% Expiration Date: jz::3<i)%ye
<br /> e/, -'
<br /> (for work on homes that were constructed prior to 1978
<br /> /
<br /> Phone:
<br /> //6;,:3— '7y-27 (office) �y„,-,/f.- (cell)
<br /> Mailing Address: �� . - j ��5 f �,/ .5-/-
<br /> ,..- City �� „t;ZIP: 53-" ":9'
<br /> Contact Person: /5,¢%C G,„ /,.,.v,7 Applicant is: Contr ca for / Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: /,)S jf �fp
<br /> Phone (day):
<br /> Address: /0 g 6 t'4,//,6/_/ S/ 7;1;1// City:ee), ZIP:rJ'3-',_
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel MCWD review&permits:
<br /> ❑ Fire Damage Minnehaha Creek Watershed District(MCWD)
<br /> IX Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<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:
<br /> Estimated Construction Valuation of Project(excluding land) $ gJ U 6.2e) , D -7
<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 refuse to supply the information,the application may not be issued.
<br /> Applicant's Signature: .4--/.e714436-,'_� Date: ,rr, / Z.
<br /> Last Updated: 08-09-2011
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