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SEP.03.2013 23:45 18004198422 All Around #0346 P.001_ /001
<br /> V - .c
<br /> L City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> A, Mailing Address; 7e)/ OV
<br /> /'�/ 0f VQ PO Box 66 Permit number: pl - y
<br /> I Crystal Bay,MN 55323-0066 Date received: c9—41--/�
<br /> �, Street Address: Received by: _
<br /> -1
<br /> ` 2750 Kelley Parkway Plan review tea:
<br /> �-kcs sit o�j Orono,MN 55356 /O
<br /> ,_r Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www,ci,prono.rnn.,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: •0 °� t,a n, 0ru.,1c ,5 Ci
<br /> V'�IU�J
<br /> Will this be a Parade of Homes, Remodelers Showcase Home 6r other Display Home? 0 Yes No
<br /> it yes,a special oven!permit is required with Police Department and City Council approval tin days prior to the event. Shuttle bus se ice will be
<br /> required unless applicant demonstrates sufficient nn sile parking is available. Non perinitled events will not be allowed.
<br /> CONTRACTOR/APP ICANT INFORMATI N:
<br /> Name:
<br /> State License#
<br /> yritru.eta,
<br /> Expiration Date: 0.6-? t-Co S,
<br /> Lead Certification Number: OqA 1-- '-Tr c , 3(0 - 4 _ Expiration Date:9 - :.19-- 0 s
<br /> (for work on homes that were constructed prior to 1978 ^"�---
<br /> Phone: (cell) 10_, Gly (Office) -7C:1--4/417-51,2.5-
<br /> Mailing Address:
<br /> 70 i Pr e-eL.0- Ar rr,. / City: 'c, ,/- , yZIP:
<br /> 5S''Y.17
<br /> Contact Person: y_-C Applicant is: -• ractor / Hdmeowner
<br /> "a' :���»�.�Wit,,:.. .. __. (circle one)
<br /> Email and/or Fax: —
<br /> PROPERTY OWNER INF�O~RMATION:
<br /> Name: -,.. �e. u,�
<br /> Phone (day): _, --�,.,......_—�_.,........_.__ ..,.,.
<br /> Address:
<br /> City: ZIP:
<br /> Email and/or Fax: _...._.
<br /> PROJECT INFORMATION: Overall project description: 'C IC:� ^c 1d-
<br /> Type of Project - "` T'—""�" L-
<br /> -
<br /> Any earth movement may also require
<br /> O Door(s) O Remodel O Fire Damage MCWD review&permits:
<br /> Re-roof,asphalt D Repair ❑Storm Damage Mlnnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> O Re-roof,cedar O Restoration El Water Damage
<br /> Deephaven,MN 55391
<br /> O Re-roof,other(specify) iding O Other:(specify) Phone: 952-471-0590
<br /> L Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek or
<br /> Estimated Construction Valuation of Project(excluding land) $ Q.c
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> Agrees to provide all Information required or requested by the Building Department:
<br /> -
<br /> • Certifies that the Information supplied Is true and correct to the best of his/her knowledge. The applicant recognizes that they ere
<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 - to annually u..- -.our re •rds and records of other governmental agencies required by law. If
<br /> you refuse to suppl the infrsfma • e ;r.. -tion
<br /> ;,,� of b: I d.
<br /> Applicant's Signature;:_ , _ a- _ /�� Date: j'-Jn/0
<br /> Owners Signature: - v Date:
<br /> /test Updated.03/001 013
<br /> c_\. -_,1„ pi,,.,..6_1 1 76.E d d r ct r )9 ) Cj
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