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, City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> � (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address:
<br /> �,�. PO Box 66 Permit number:
<br /> � � �„ �
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> , , ,
<br /> �,� � ,��:__ �, Streef Address: Received by:
<br /> � .:,r,e `,
<br /> �,�,t �'� �ti 2750 Kelley Parkway Plan review fee:
<br /> y,kESHog'� Orono, MN 55356
<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 appfications will be returned. (Please print)
<br /> GENERAL INFORMATION:; f ,--
<br /> Job Site Address: ��� c�,�lg �i' r-
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br /> If yes, a specral event permit is required with Po(ice Department and City Council approva/60 days prior to the event. Shuttfe bus service will be
<br /> required unless appficant demonsfrates sufficient on-sife parking is avaifable. Non-permitted events wil!not be allowed.
<br /> CONTRACTOR/APPLIC NT INFORM TION:
<br /> Name: r/nr�2�C'Sf- .5�,,�
<br /> State License# ��C��p�7 -7 Expiration Date: �=-3 l--� ,�
<br /> Lead Certification Number: /�`�.�_ ��3�'S--_( Expiration Date: � �5--- /�—
<br /> (for work on homes that were consfructed prior to 1978
<br /> Phone: ' ; (�3.-(.���. ��;�� (office) (cell)
<br /> Mailing Address: �(j-/ S �., G . City: � `y-,�-�,,,� ZIP: ,s`�3�c
<br /> Contact Person: �f`,�� ,,f�,�S�� Applicant is: ntra tor / Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �6yyl l(,,e�S�'��
<br /> Phone (day): ( �7 S` g:� �II
<br /> Address: (��7 S�� �c�rs,� ��--� L�,,_ City:�'/,���,,�,,��.?��� ZIP:
<br /> Email and/or Fax
<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 /> ❑Window(s) www.minnehahacreek.orq
<br /> Overall Project Description: � � _ �� � �
<br /> Estimated Construction Valuation of Project (excluding iand) $ �O U
<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 sofely 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 applicafion 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 /> re uired b law. If ou refuse to su I the information,the a fication ma not be issued.
<br /> ApplicanYs Signature: � Date: ( �� �
<br /> Last Updated: 08-09-2011
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