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Ci�y af Orono . �,'�
<br /> � .
<br /> Br�ilding Permit Appiicafion for Maintenance / Renovation �t,
<br /> � � (windows, doors, siding, re-roof, etc.) � '`
<br /> Nrailing Address: Permit number:
<br /> �,L,0,� PO Box 66
<br /> �� Q Crystal Bay, MN 55323-0066 Date received:
<br /> � ��'r,. �
<br /> �1.� "'f',�` a, StreetAddress: Received by:-
<br /> ��' ' "l'�'�y ti 2750 Kelle Parkwa
<br /> � o Y Y Plan review fee:
<br /> L`�,,'�ESHo�`� 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 /> incompfete appfications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address �� S �;; �� > ` �G�7 �,
<br /> Will this be a Parade of Homes, Remode ers Showcase Home or other Display Home? ❑ Yes o
<br /> If yes, a special event permit is required with Police Department and City Counci/approva/60 days prror to the event. Shuttle bus servrce will be
<br /> required unless appficant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed.
<br /> CONTRACTOR/AP�LICANT INFORMATIOI�:
<br /> Name: ��5��' �f�,�,5'��;.,�,'j-��
<br /> State License# - � 5 7 Expiration Date: �--31_l�-�
<br /> Lead Certificafion Number _ �_�� Z�2 —� Z—�V� -�� Expiration Date: � E—/ �
<br /> (for work on homes that were consfrucfed prior to 1978
<br /> Phone: c�( Z—2lC`��/��� ��c 11� (office)7��5--�/"7`�'�i'��c�� (�+H--
<br /> Mailing Address: ,.,.�r�� � ��` : S > City:__ ,/�'d�:y, ZIP: ,.y��S�
<br /> Contact Person: � � C . ..�- -�,� Applicant is: Contract / Homeowner (Circfe One)
<br /> Err�ail and/or Fax: �`� �;., ,�� ,f��i�. �� e��f.ti
<br /> PROPERTY OWNER INFORMATIOH:
<br /> Name: � ,;� �,.r.` c
<br /> -t� �'.i
<br /> Phone(day): � •
<br /> Address: �`f.5� �,t�Q�� rJ��.�e:� City:��'c,�,� ZIP:
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review&permits:
<br /> ❑ D or(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD)
<br /> � Re-roof,aspha�t ❑ Repair ❑ Storm Qamage 18202 Minnetonka Bfvd
<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:J�r�, . a ,� �F�u�
<br /> Estimated Construction Vafuation of Project (excfuding land) � �,�Cj�
<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 alternafive
<br /> but to reject it unfil it is complete;
<br /> i • 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 pubfic but can be given to the subject of the
<br /> data. Confidenfial data is infor afion which generally cannot be given to either the public or the subject of the data. Our
<br /> purpose and intended use o s � mation is to annually update our records and records of other governmental agencies �
<br /> required b faw. If ou ref e t the information, the a fication ma not be issued. �,
<br /> �
<br /> Appficant's Signature: Date: / ��� �/ �
<br /> Last Updated: 08-09-2011
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