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� City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Remodel
<br /> (i.e. a�rindow�, dac�rs, �iding, re-ro�f, �tc. — �TRUCTURAL EXPAN�I4N)
<br /> ,%��� ^' '��, Mailing Address: � �
<br /> ;/ ��<VO\ PO Box 66 Permit number Z-C��'�C�( (��
<br /> �� Crystal Bay, MN 55323-0066 Date received: -�7
<br /> � � ( ; -
<br /> f Street Address: Received by: -� � `
<br /> ���S� ��� 2750 Kelley Parkwa�� C.�L �Q Plan review fee: , 7 /
<br /> �,\�y�, ��,;� Orono, MN 55356 ,' + - � �
<br /> ` -�����-% Total Fee: �' '� L�a.
<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. (�y�� ����
<br /> Incomplete applications will be returned. (P/ease print)
<br /> GENERAL INFORMATION:
<br /> �-
<br /> Job Site Address: �� 3 G' �C� � ,��-'�
<br /> Will this be a Parade of Homes, Remodelers Showcase 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�rvi e will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: W,�� �i�.t � �cx L,
<br /> State License# . Expiration Date: —
<br /> Lead Certification Number: - Expiration Date: �
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) (i/�,� ��7 -�a7� (office) `�J�.- �{ � � -U�/Y
<br /> Mailing Address: ?�� 3 p �� <� ,t,v.� City: �,,�U,�,�, ZIP: �
<br /> Contact Person: I„/� / �,,,, �;j/ �� /�, Applicant is: Contractor / eown�r (Circle One)
<br /> Email and/or Fax: (��<1,,,; ��r«<--, C� �I�.v«r r�. < ��,,,,
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �i f �r.r�� K(�c L�
<br /> Phone (day): (Gj(a� .�� 7-��,� � ( (� !1�
<br /> Address: 37 �O �G t�� �v� City: (�,-�v,� ZIP: s� 3�J/
<br /> Email and/or Fax: kE%�I��,�� ��iu�,,, �, �j;,N�i,l,� c,,�,�,
<br /> _/ )
<br /> PROJECT INFORMATION: Overall project description: -1�� � CY/L�C ��.'/`7�`�(,i�
<br /> Type of Project: Any earth ovement may also require
<br /> �Door(s) ,�Remodel ❑ Fire Damage
<br /> M D review 8�permits:�����;
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> ❑ Re-roof, other(specify) �Siding ❑ Other: (specify) Phone: 952-471-0590 C�� 2"
<br /> Fax: 952-471-0682 �
<br /> �Window(s) www.minnehahacreek.orq ��
<br /> Estimated Construction Valuation of Project (excluding land) $ '�iJl�--�S
<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 are
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to
<br /> 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 data.
<br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I the i r ati ,t e lication ma not be issued.
<br /> ApplicanYs Signature: Date: '( L L � S
<br /> Owner's Signature: Date: � Z l�
<br /> Last Updated:January 2015
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