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SEP-3-2014 09:50 FROM:TREBILFOUNDATION SYS 3205938720 TO:1952249461E P.2'6 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc. <br /> Mailing Address: Permit number. 1.Q Ill-Op q qr <br /> P(:;:ilas <br /> 0, Cry tel Ba Crystal Bay,MN 55323-0066 Date received: �'-3-1� _ <br /> '\,,` Received by: I -E- <br /> k`')i:1-*19' <br /> Street Address; <br /> - <br /> 2750 Kelley Parkway Plan review fee- $ i.9 <br /> Orono,MN 55356 <br /> Total Fee: �. <br /> Main: - b Fax; 952-249.4616 www r on mn u _ �� <br /> 952 2 9-4600 _ .c,Qr �1� <br /> This application form must be completed in full and all required information must be subreitted.--' <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ,20-0 U30edJ\'aU ed • <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 171 Yes No <br /> ft yes,a special event permit is required with Police Department and City Council approval 60 days prior to the avont. Shuttle bus se will be <br /> required unless applicant demonstrates sufficient onsite parking is available. Non-permitted ovonts will not be allowed. <br /> CONTRACTOR I JiivAPPLICANT INFORMATION: <br /> � <br /> Name' Tt �?1l�r trt�s., <br /> State License# `(� Li.LILD LIS f Expiration Date: Z.., <br /> Lead Certification Number;,. -1- j '1 Expiration Date: 41l(o ( U(Q <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: r 8'7r 9 (office) (cell) <br /> Mailing Address: r/,fir C. City: .ax - ZiP: <br /> Contact Person: .AM I: ea' dr Applicant is: ' ■ntractor / Homeowner (Ctrcieone) <br /> Email and/or Fax: - <br /> PROPERTY OWNER INF RMATION: <br /> Name: 1J00.i i 1 'gif. .. . -3 <br /> Phone(day): As - • :2 <br /> Address; ,,.44 - ..A.•...iMr!1. . City: Orono ZIP: 55 391 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project; Any earth movement may require <br /> 0 Door(s) 12Remodel ❑Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> d Re-roof,cedar 0 Restoration ❑Water Damage Doophaven,MN 55391 <br /> Cl Re-roof,other(specify) ❑Siding <br /> Phone: 9952-471-05900 <br /> ❑Other:(specify) Fax:: 952-471-06822 <br /> Cl Window(s) www,minnehahacreek,oro <br /> Overall Project Description: (��� Q Q Ch <br /> Estimated Construction Valuation of Protect(excluding land) S 5-7/4g 0.se <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 bylaw. If you mfuee to supply the Information,the application may not be Issued. <br /> Applicant's Signature: r <br /> 4- IA tk Mu MST`: Date: q,f 3 I 1 <br /> Last Updated: 08-09-2011 <br />