� ` City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.) C.� ��l I
<br /> =__> Mailing Address:
<br /> ��,�,� PO Box 66 Permit number: ��j- - �,
<br /> Q, \ Q Crystal Bay, MN 55323-0066 Date received: 02 -a,D- 13
<br /> a l����'?�,� '. �, Street Address: Received by: �''✓� L..D
<br /> �'�nt���y;;����,ti 2750 Kelley Parkway Plan review fee:
<br /> `�kEsxo4'' 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 applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: � ` . ��. �� �_
<br /> Will this be a Parade of Homes, Remode ers Sh case Home or other Display Home? ❑ Yes 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 s rvic ill be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT�[INFORMATION: j �
<br /> Name: �'•1...,� T7 ��,r.e 2�t..t i �-���'� L-�-C_
<br /> State License# • � � Expiration Date: , �
<br /> Lead Certification Number: ' ,-� � . , �� �� `���
<br /> �s ��L�,�j���� -�G,� Expiration Date: ��,� � f �y j�
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: ` � � � , '" ,�' " (office) ,. , ', Li `j (cell)
<br /> Mailing Address: G�j�j � �' �;, ,� ,. City: (_t�� • �,,��5 ZIP:
<br /> Contact Person: ��.� ,� Applicant is: ontractor / Homeowner (Circle One)
<br /> Email and/or Fax: �c's �t1 �)f� i �+��1��1j'i.dt.��� (Cl32 �-!�; �' •:�l?jG� . �,�L�l�'
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: [� � ,r� � ��,���..� �-� �
<br /> Phone (day): - - .
<br /> Address --f `s City: %� : ZIP:
<br /> Email and/or Fax q : ., „ ' � <� �.t
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�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) �(�e'�y�Q��"�i�j Www.minnehah�creek.ora
<br /> Overall Project Description: ` >Y/ , " c��e�r �' tn�.-- c�-!r� �'✓:;r - �fJla�
<br /> Estimated Construction Val tion of Project(excluding land) $ Gjn,���, G?t�
<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 /> re uired b law. If ou refuse to su I the information,the a 'on ma not be issued.
<br /> ApplicanYs Signature: Date: d����,3
<br /> Last Updated: 08-09-2011
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