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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: -2(5/1-06 a'/
<br /> 1 430 Crystal Bay, MN 55323-0066 °Date received: f'; f�
<br /> ,. Received by:
<br /> ,� �, Street Address:
<br /> ( ; � ti 2750 KelleyParkway
<br /> Y Plan review fee:
<br /> �r9 ��'' lr` �' Orono, MN 55356
<br /> kEgHO� 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: Z.Z 5' O _>, / /e z � r
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes 8 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: 6- C t ,,� ) cl,�.i
<br /> State License # -7.J 6 a 6,s—' C Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: c 5 a - s?- z ', (office) (cell)
<br /> Mailing Address: / 76 t,t,,ir A0 -c, , City:/276, c/.e0,.. ZIP: _. --_5--,?‘'6
<br /> Contact Person: G,, _ ,Q, Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: , ,\,\, '7, 1)mc Al
<br /> Phone (day): ./73_.612 y
<br /> Address: ' S`' ( /4.2 c,, D r,, City: ZIP:
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel CIFire Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> kRe-roof, asphalt ❑ Repair E Storm Damage 18202 Minnetonka Blvd
<br /> El Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) IVSiding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq''
<br /> Overall Project Description:, 1-:,6„4. V rte,r c/ (a a s.�H� c3.v s V
<br /> Estimated Construction Valuation of Project(excluding land) $ 3 -7Q n
<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 t supply the information,the application may not be issued.
<br /> Applicant's Signature: / s Date: Ar_l_47/__, d//
<br /> Last Updated: 08-09-2011
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