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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: C �c (1640 L.( <br /> (3.4 CO Bax 66 <br /> ‘fk, Permit number: 1 <br /> _'' Crystal Bay, MN 55323-0066 t'Date received: ` 7—9--/ <br /> e\" :Received by: � �- <br /> a \l\ yii ti Street Address: <br /> �" l�� ,ray ti 2750 Kelley Parkway Plan review fee: <br /> -13/4-......v. Orono, MN 55356 <br /> Total:Fee: ,47(-4, ,, - <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) /11s.7 /10�/z <br /> GENERAL INFORMATION:, <br /> Job Site Address: 103D CA)i LLOkJ cJ(E(.) ------ ,2 We' , <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: T,ES (od.:../-77f}L S ; vice` S live . <br /> State License# 2-ozz Lid.Leg Expiration Date: '317 r JZ�r LI <br /> Lead Certification Number: Expiration Date: / j <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 3 Z - 3 3 L(_ 3 ogco (office) (cell) <br /> Mailing Address: -.1(4 ( L -7-.. A_c, _ City: f'Ll 7764 ZIP:G yS- <br /> Contact Person: ----"f 14_/4., 1K_Ir2/4,-6 , Applicant is: ( ontractor , Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: `E ( t_A-u,'UA LO A-Lc-61,i r :< <br /> Phone(day): * -5--Z - Liz Ce - ei(37 <br /> Address: `a (03 o Lc)ILLoc..0 vILE.c,J `72 City: Cjred,Jo ZIP: S�3.T <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits: <br /> ❑ Door(s) emodel ElFire Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ElRe roof, other(specify) Phone: 952-471-0590 <br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> El Window(s) www.minnehahacreek.orq <br /> Overall Project Description: NS-,---(A c_c_v0,—Lc-` / —( 77,ti; — Iie1w, - r x«c_ts,` iEoD"- <br /> Estimated Construction Valuation of Project (excluding land) $ (-,-2( .D ° <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 info ation is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to su9ply hhee informati•n`;the applicati• may not be issued. <br /> / <br /> Applicant's Signature: ___f_4:: <br /> Date: Cl I Z <br /> Last Updated: 08-09-2011 <br />