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r ' <br /> City of Orono <br /> Building Permit Application for Maintenance / ReplperTent.4emodel R - Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. STRUC RAL EXPANSION) <br /> OA, Mailing Address: / ;qo/ 1-00/ 97 <br /> �'� `YO y� PO Box 66 <br /> Pe it number: <br /> ftL Crystal Bay, MN 553 -0i.09 1-'4L" B;te received: <br /> E./ct+i Street Address: Re <br /> a 2750 KelleyPa ayL r '�'��� o)o/ ! <br /> y� Pan review ee: 7-� <br /> �ktstior- 3 ` Orono, MN 55356 Cr6-; 5f3. t� <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: 1 <br /> Job Site Address: l 9 9 IA) l\lUw T r - <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes 119.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/APPI,,ICJ�M <br /> ANTi INFOATION: •c� <br /> Name: IC CA2Z-11(",� J (A)✓) ) ✓) tl <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) b/2 - ,s2-9-cz9 Z Z (office) <br /> Mailing Address: q )d--k A V '[' So City: /c�-PL a ZIP: S S'-123 <br /> Contact Person: 1--V1 1 O(A.) Applicant is: Contractor / �-lomeowner (circle one) <br /> Email and/or Fax: 1ai. d OCCA) n n c'1 11) 14•/ L (,Vw,% <br /> PROPERTY OWNER/INFOR ATIO o C <br /> Name: I` Q�- © (�1> > O� J&�) Q'�G �o/Z-34 3` `1L0 <br /> Phone(day): t� /2 - � q, 14 9 Z <br /> Address: '7 L( 2/ ( 04- JQ V� � City: 1C.J7`t')vale/ ZIP: SS9 23 <br /> Email and/or Fax: /<' t csW � <br /> Uy� n �, ('j rV1 a, L , c,'V1 <br /> � U <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: / Any earth movement may also require <br /> ❑Door(s) I�Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar 0 Restoration 0 Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ 51 ® 0 0 <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 information,the application may not be issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: A". / Date: rna P. 2 , 20 <br /> Last Updated:January 2016 • <br />