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City of Orono � /�8 �7.5
<br /> Building Permit Application for Maintenance I Replacement / Renovation
<br /> (No structurai expansion. Only windows, doors, siding, re-roof, etc.)
<br /> A , Mailing Address: Permit number: 020 ( -� 0���
<br /> �Df VO PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: .3 - J� - )
<br /> � � 1 Sfreet Address: Received by:
<br /> ' ' � � � 2750 Kelte Parkwa � �5�Q 7 33./9
<br /> � :.� Y �� Plan review fee:
<br /> ` ��,�•�,t` Orono, MN 55356 07 p/ -- p D/�.3
<br /> �t� ��,r .
<br /> ___ Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616
<br /> This application form must be completed in full and all required information must be submittec� C��
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: . �- , � �jB�fL
<br /> Job Site Address: . �, �j�'� �`;r�1L ����-.:
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes N
<br /> ffyes, a specia!event permit is req�ired with Police Department and City Council approva160 days prior fo the event. Shuttle bus se i w"1 be
<br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be aflowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: '
<br /> �� ���,�c.n,�, -�_:;J� r.-, , �•�<-
<br /> State License# p�, j�u ss'���,; Expiration Date: `ii�,;L;, �; ,;�,.,y`
<br /> Lead Certification Number: �/,�q�r- ���� �,_;,;�-� Expiration Date: j�l�� �y , a�,t,,
<br /> (for work on homes that were constructe�d prior to 1978
<br /> Phone: (cell) CaiL 750 �)�'� �Juy�.�r� (o�ce) �I�:-� ��>> a3�.�
<br /> Mailing Address: ��-��� ����.,,., hu�� City: M,,,.,��,,,,�„ ZIP: Ss�r`-
<br /> Contact Person: �c�+�! ;�. ;�.�,-e�n�� Applicant is: C ra or / Homeowner (Circle One)
<br /> Emailand/orFax: '�dur� �c. ms��. «�rl
<br /> �
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ;:r� .� � Td�v���c Sr��-�-;,:.,1
<br /> Phone (day}:
<br /> Address: City: ZIP:
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall ro�ect description:
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) � emodel ❑ Fire Damage MCWD review 8 permits:
<br /> ❑ Re-roof, asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> ❑ Re-roof,cedar ❑Restosation ❑16�Lates Qamage � --� Desphaven, MN 55391
<br /> ❑ Re-roof, other(specify) ❑Siding ❑Other. (specify) � ``�phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑Window(s)
<br /> Estimated Construction Valuation of Project�excluding land) $
<br /> APPLICANT ACKNOWLEDGEMENT: � iN.j� ���}�� ��'��r�'' ', -� �,, , ��, �7 �yG �
<br /> • Agrees to provide all information sequised os sequested by tkze Bui4din epa ment;
<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 ans►ually update aur recosds and recasds of other governmental agencies required by law. If
<br /> ou refuse to su I the inf ati , th li tion ma not be issued.
<br /> Applicant's Signature: Date: ' � � �u%
<br /> Owner's Signature: Date:
<br /> Last Updated:03/06/2013
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