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City of Orono -'// 2.1
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address. .Permit!number€;
<br /> 4,...K:1-4::O,jET PO Box 66
<br /> Crystal Bay, MN 55323-0066 'Datexeceived:
<br /> a �' �, ,�, Street Address:• Received by:
<br /> 1'�n li "i'o ti 2750 KelleyParkway
<br /> •l Ptan:reaiiewfee
<br /> lkes-acri°' Orono, MN 55356
<br /> 'Tota1 Fee.
<br /> G.I '• s sE.»(
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us r ,G't„y;,, 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 INFORMATION:
<br /> Job Site Address: /8(00 7-0,t1 -w4-- ia'4Q
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes X 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/APPP,1}J- 9ANT INFORMATION:,
<br /> Name: lKiclk C.�eI1- •o 4J ` y' tke St/to tioyvv, Lt,c ,
<br /> State License # RC.3o1%o (e Expiration Date: ? lad/
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (office) ea l Z - 8.S0 - ydoZ (cell)
<br /> Mailing Address: it G( W t4 /?LI/,p '', Ai, ZaB, City: w e ZIP: S.s-j9,'
<br /> Contact Person: 'i-C< C4at-Say,/ Applicant is: -. .c or / Homeowner (Circle One)
<br /> Email and/or Fax: R«(G Q. Gu4-7-f4.. ?F ,nut,s . con.,
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: 41 44/ rye G,,-„<S,,'/a -.
<br /> Phone(day): 42.5-1-3 - S2/ - -2--72 a
<br /> Address: 2.2 S7,4ltwod6 ,r.)R• City: Wcle 3 i U, ZIP: yqc d(Q 2_
<br /> Email and/or Fax lrnLL14-0'1 LAS/n/ ,- 0- e-m.1r-. , cq,,,.
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel E Fire Damage MCWD review&permits:
<br /> E Re roof, asphalt ❑ RepairMinnehaha Creek Watershed District(MCWD)
<br /> p E Storm Damage 18202 Minnetonka Blvd
<br /> Re-roof, cedar XRestoration ❑Water Damage
<br /> Deephaven, MN 55391
<br /> ❑ Re roof, other(specify) Phone: 952-471-0590
<br /> ❑ Siding E Other: (specify) Fax: 952-471-0682
<br /> w
<br /> ❑Window(s) ww.minnehahacreek.orq
<br /> Overall Project Description: ,4-7R bEck/ /�iD/n/4,--1 C1l/nyr , /9P,42/1-\ /04y---6,42.. ,yt, -6
<br /> Estimated Construction Valuation of Project (excluding land) $ //O,02,0
<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 by law. If you refuse to s ly th information,the application may not be issued.
<br /> Applicant's Signature:
<br /> Date: 742-4 2,.
<br /> Last Updated: 08-09-2011
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