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01/28/2015 11:22 952-935-9544 MN RUSCO PAGE 02/02
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<br /> City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. only windows, doors, siding, re roof, etc ) ']
<br /> ��r Mailing Address: Eier ilt number ''h' 14!,.64V.:440.;;,;7 q '
<br /> �Y PO Box 66 �in y
<br /> Crystal Bay, MN 55323-0066 ,Date received l �1 ,
<br /> .2 Received by • .". 2:,
<br /> Street Address: r
<br /> 2750 Kelley Parkway Plan review fee
<br /> 17141L7E� Orono, MN 55356
<br /> 4600 Fax 952-249-4616 www,cLorono.mm�.us Total Fee H r l ►
<br /> Main: 952-249
<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 /> - / I I �/N ' 553(dJob Site Address: v I - - i
<br /> Will this be a Parade of Homes, Remodelers Showcase Ho e or other Display Home? ■ Yes e'No
<br /> If yes,0 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 1 AP- ICANT 1NFOR i•TION:
<br /> Name: la i t'it' -a ..4 A -
<br /> State License# ., QD 2-1 _ Expiration Date: 0331,f(p
<br /> Lead Certification Number: Lite 2. -Q Expiration Date: 08,11./5
<br /> (for work on homes that were constructed prior to 1978 �1 f
<br /> Phone: (cell) "r32, ‘4,3... • q . ��!• (office) 9 ' ' ,' T1
<br /> Mailing Address: _ .,.� Ai ,,; t, Iuv City: /M7/ , ' ZIP: 5 5 3 _
<br /> Contact Person: _ iyuyi vo&g Applicant is: onttacto / Homeowner (Circle one)
<br /> Email and/or Fax: ,r • Ir, , f : dr-•,_ r , 0• ai - •q.0 ' .,
<br /> PROPERTY OWNER FORMATION:
<br /> Name: Li, e. f I', ,' / • -•1L.%
<br /> Phone (day): dz. ..0 i y �� I pry, �,�
<br /> Address: 5',,� City: V"wi�0 ZIP: A..
<br /> Email and/or Fax: -reiv15-�k- re.:r e: ' i CI S' e�
<br /> iC2pik afRi• 164 dif/c)-fr;
<br /> PROJECT INFORMATION: Overall •ro ect descri•tion: lI// r 2/ wj/lia(o'
<br /> Type of Project: Any earth movement may also require /S/1 d7/
<br /> MCAD review&permits: `�
<br /> ❑Door(s) 0 Remodel ❑ Fire Damage
<br /> Repair ❑ Storm Damage Minnehaha Creek WA
<br /> Watershed District(MCD)
<br /> D Re-roof, asphalt © 18202 Minnetonka Blvd
<br /> ❑Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55351
<br /> LI Re-roof, other(specify) El S. ingiii0Other: (specify) Phone: 9521371-0590
<br /> Fax 952-471-0682ndow(s) _ www rninn hahacreek.4rq
<br /> Estimated Construction Valuation of Project(excluding land) $ %i, /f
<br /> i
<br /> APPLICANT ACKNOWLEDGEMENT;
<br /> • Agrees to provide all information required or requested by the Building Department; ,W
<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 date is info • atlon which generally cannot be given to the public but can be given to the subject of the data.
<br /> Confidential data is information Mich generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this informati.y Is to annually u•date our records and records of other governmental agencies required by law. If
<br /> _ ou refuse to su••1 he Infor..�4�/.!Ia atio• t, ;••i .;o ma not be issued.
<br /> Applicant's Signature: 1,2VVI Date: P.2.0 'f5
<br /> Owner's Signature: _ Date:
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<br /> Lest Updated;03/06/2013
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