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Nov 11 2015 11 : 11RM HP LASERJET FAX p. 1 <br /> • <br /> City of Orono /$7r72 <br /> Building Permit Application for Maintenance / Renovation <br /> 1. (windows, doors, sidin , re-roof, 0th.) <br /> •titoa <br /> Meiling Address: <br /> PO Box 58Permit number: __D/ ,5S <br /> 0 O Crystal Bay, MN 55323-0066 Date received: ///07/s- <br /> +. <br /> ;t 1 ,,,,, <br /> Street Received by: <br /> �•� I G 2750 Kelley Parkway <br /> �t - - . Orono, MN 55355 <br /> pian review fee: <br /> Main: 952-2:49-4600 Fax: 552-249-4615 Total Fee: /�Q��8 <br /> www.ci.orono.mn.0 <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 INFORMATIDN: <br /> Job Site Address: 4 Do-P.r. . 3•, / , 44-Ke. 553 <br /> Will this be a Parade o Homos, Remodeiers Showcase Home •r other Display Home? ■ Yes No <br /> If yes,a specie/event pe It is required With Police Department and City Council approval e0 days prior to the event. Shuttle bus service will be <br /> required unle applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: /1 /4l pj _d2 <br /> State License# _43.2 8, <br /> Lead Certification Number: j 7 — Expiration Date: _ <br /> (for work on homes that were cvnstructed97 <br /> prior to 1 ; Expiration Date: <br /> Phone: 467- 7]O - p0/ (office) <br /> Mailing Address: r ,Q /.- 'e', (cell) <br /> Contact Person: � -4,_,._ City"��� � .r.", ZIP: �.S�lpc� <br /> Applicant is: �/ Homeowner (grow one) <br /> Email and/or FaX d_5-/ -,170- EL _ V , cr..16/Peedie?oRcb ,s/ C, <br /> PROPERTY OWNER INIORMATION: <br /> Name: .ir A ! O 'd_O n/. 0 R, <br /> Phone(day): j-, 6 -_6-1•._5 i - nal :�,4,3.71--564bF- <br /> Addresa: �oNNr‘Rk�/ <br /> -A 11 OO- - • / City: d O ZIP: `.53 .. <br /> Email and/or Fax i ` it - • A a %-indirall <br /> PROJECT INFORMAT,ON: <br /> Type of Protect: Any earth movement may require <br /> © Door(s) I 0 Remodel ©Fire Damage AIiCWD review permits: <br /> ❑Ra-roof,asphalt 0Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar I 0Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑Re roof,other(specify) 10 Siding phone: -0580 <br /> ❑Other:(specify) Fax: 9522.471-.471-0882 <br /> iI►�/ Window(S) Syww.minnehahacreek.org <br /> Overall Project Dascri•tl!•n; <br /> Estimated Construction ! eluation of Project exciudln. land $ a , . .e:, <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees required or requested by the Building Department <br /> es to provide all nfor <br /> • Certifies that the Information Supplied Is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> ere solely responsible far submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject It until it ie complete; <br /> • Some or all of the inlOrmatlon that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private ate is information which generally cannot be given to the public but can be given to the subject of the <br /> data, Confidential d to is Information which generally cannot be given to either the public or the subject of the data, Our <br /> purpose and intende use of this Information is to annually update our records and records of other governmental agencies <br /> re.uired b law, if o refuse to su••I the information the a.•//cation me not be issued, <br /> Applicant's Signature: , / - / <br /> Date: r 0 //,� <br /> Last Updated: 08-00-2011 / —' <br />