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��,c�-�' �� �� City of Orono �, � ��-�5
<br /> �uildin Per�it A lication for Maintenance / Renovation
<br /> 9 pp
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: 0 dd 1
<br /> �,0,�. PO Box 66 Permit number: o?��a `
<br /> � a,_ �
<br /> Crystal Bay, MN 55323-0066 Date received: 3 a�-
<br /> ��r�� � �, Street Address: Received by:
<br /> '$',�,�,��'�`�,;j,� �ti 2750 Kelley Parkway Plan review fee: �8 T• q
<br /> 9kESH0� Orono, MN 55356 �ol a—d��-/ 3 2���
<br /> -'_� Total Fee:
<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:
<br /> Job Site Address: l�S� ,° � �p�G�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o
<br /> If yes,a specia/event permit is required with Police Department and City Counci/approva/60 days prior to the event. Shutt/e bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/AP�I�ANT INFORMATION:,�
<br /> Name: '
<br /> State License# �q� Expiration Date:
<br /> Lead Certification Number: �p �t'� - Expiration Date: `
<br /> (for work on homes that were constructed rior to 1978
<br /> Phone: 5 a, -`� ` --� �� (office) (cell)
<br /> Mailing Address: js' ' �� City: �,, ,�;,,,5 ZIP: S -
<br /> Contact Person: Q�, Applicant is: n / Homeowner (Circle One)
<br /> Email and/or Fax: ' � ,v� . ?��
<br /> PROPERTY OWNER INFORMATION: � 1�LC� � �C�e(�'i Prc�Fc�- i'�(�✓' (('� (cl L -�q� —
<br /> Name: ,� /C� � S�Arz� �tis�-�,'e�� �13.3
<br /> Phone (day): a-s�'� _ O
<br /> Address: ��, City: �r-� c� ZIP: �
<br /> Email and/or Fax �
<br /> _ �'�
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> � Door(s) [�Remodel ❑ Fire Damage MCWD review&permits:
<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 /> Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑Other: (specify) Fax: 952-471-0682
<br /> indow(s) www.minnehahacreek.orq
<br /> Overall Project Description: ' (�y , � .,,, �,�, r �,,N�, y�',,; ,,,, I� sH
<br /> Estimated Construction Valuation of Project(excluding la d) $ di` ��,��� w�S"t �,`�
<br /> .ft �
<br /> APPLICANT ACKNOWLEDGEMENT: �'"'��'J
<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 tQ 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 iven to either the public or the subject of the data. Our
<br /> purpose and intended use of this information is to annually''update r records and records of other governmental agencies
<br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued.
<br /> ApplicanYs Signature: - �` L/�� Date: � ��, .� �
<br /> Last Updated: 08-09-2011 ''r� t
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