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City of Orono <br /> Building Permit Application for (Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> `x jam. Mailing Address: Permit number: OAU/ �&0 <br /> PO Box 66 _ <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Received by: <br /> Street Address: ==y� � <br /> A. i 2750 Kelley Parkway Plan review fee: g� <br /> xE s o � Orono, MN 55356 C <br /> H --------------- <br /> -1`Otal—Fee- <br /> Main: <br /> Main: 952-249-4600 Fax: 952.249-4616 www.ci,orono.mn.us ;) S <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: 10- C�evy 61A-- ,L, DK <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> n yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttfe 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: L L g,Jd ev-c <br /> State License# LSC_y-d fi Expiration Date: TZ311 14 <br /> Lead Certification Number: T_ _13 4 7 i_ Expiration Date: <br /> (for work on homes that w re constructed prior to 1978 <br /> Phone: (cell) - -7 So - 7 p 9 (office) 9S� - ao0- 9 34 <br /> Mailing Address: 1 7 G Ave. City: 1,1 d ZIP: -3-79 <br /> Contact Person: Applicant is: ontracto / Homeowner (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION-- , __ <br /> Name: /�) ' i,a k- o,��� l _w VX <br /> Phone (day): s d---;)� I <br /> Address: 100 Ll,cvy 66v- Q^, City.0tv-0 ZIP: _� 5 <br /> Email and/or Fax: (!ia/) <br /> I., �+.nw� � �w\>c� <br /> PROJECT INFORMATION: Overall project description: <br /> T of Project: =-_._ <br /> TypeAny earth movement may also require <br /> ❑Door(s) Remodel ❑Fire Damage MCWD review&permits: <br /> Q Re-roof, asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCW D) <br /> ❑Re-roof,cedar ❑ Restoration Water Damage g Minnetonka, Blvd <br /> 320MinnnaMN55345 <br /> ❑Re-roof,other(specify) 0 Siding ❑Other:(specify) Phone: 952-471-0590 <br /> fJ Window(s)Kf Fax: 952-471-0682 <br /> W w minnehahacreek ora <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> _ <br /> APPLICANT ACKNOWLEDGEMENT: — <br /> • Agrees to provide all Information required or requested by the Building Department, - <br /> • <br /> Certifies <br /> ely responsible fo�submittimation ng supplied com I ie andlicationtto beinhebest of aware that his/her knowledge. The applicant recognizes that they are <br /> n9 P PP 9 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 Stats law as either private or <br /> oonfidential. Private data is information which generally cannot be given to the public but can be given to the sub <br /> Confidential data is information j of the data. <br /> mended use of this information Is too ach nnualiylupdate our rly cannot beecords iven arxlerecords of or the ltheic M the subject of the data. Our purpose and <br /> you refuse to supr>1y a information,the application may not be issued - 9E►vnmental agencies required by law, if <br /> /h Applicant's Signature: Date: �`'l� /6 - <br /> 0vrner'S Signature: Date: <br /> -- <br /> Vdated:Janmry 6 <br />