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<br /> City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number. ��/ - � � �
<br /> O�,D,�.O PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: �� `�/—
<br /> s,���„ �
<br /> a ���,;`: s, Street Address:
<br /> Received by:
<br /> �'�,t ` G: 2750 Kelley Parkway Plan review fee: g • �
<br /> .ykE$�� Oronq MN 55356 '
<br /> Total Fee: � v��`����
<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: �Sp �od --p�--�,, �.-v�,�., ,1�.:a�c� �.
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes (�No
<br /> lf yes,a special event permit is required with Police Departmenf and City Council approval 60 days prior to the event. Shuttle bus service wif!be
<br /> required unless applicant demonstrates s�cient on-site parking is available. Non-permitted events will nof be allowed.
<br /> CONTRACTOR/APPUCANT INFORMATION:
<br /> Name: G, Tdi a wi rtS L`c�h s�r cY�.��a^ �'.`a ,
<br /> State License# ��,, �<,Z�y�; -J-r Expiration Date: '�. r� . �o l 3
<br /> Lead Certification Number: �(J,47-_ c,�3•-/��_ � Expiration Date: /�� _ z c; - z O� �
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: ��,�����, .. �,�'�� (office) � �a'> �;�m �;� '�„�°" (cell)
<br /> Mailing Address: �J -��,�, ��'�� �j., �,f,�,•x� City: .'�"-�'r �� ZIP: ����
<br /> Contact Person: �;,,^+,�,.x,� �,�w. ,,, Applicant is: ontractor / Homeowner (Circle One)
<br /> , �
<br /> Email andlor Fax: �, -r�-�:-,..,.�:..�r + � �<; � ��'���� �„� ���,�. �"a�,
<br /> �.
<br /> PROPERTY OWNER INFORMATION`.
<br /> Name: CxJar.�e�, ��.�t° l ��� c'��+y��� ��
<br /> Phone(day): �S z_t�`7�a,~ �2,�'�,r
<br /> Address: ��'t.� /'Ir�os.�� ;;,�'��"�.�,�: x �'`}��,�� CitY: �,����.,�.,� Z►P: .�..`,..���yv
<br /> Email and/or Fax --____,
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review 8�permits:
<br /> ❑Door(s) �Remodel ❑Fire Damage 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) W�•minnehahacreek.orq
<br /> Overall Project Description: ��,a o���, - �a�� �a�,,, �°,:�� �,�.��;.., ;t'o,.�;,� .
<br /> Estimated Construction Valuation of Project(excluding land) $ �,���- �
<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 altemative
<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 � ormation is to annually up ate our records and records of other governmental agencies
<br /> re uired b law. If ou refuse t I the information,the a ication ma not be issued.
<br /> ApplicanYs Signature: � ��� Date: � � Z� !/
<br /> Last Updated: OS-09-2011
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