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City of Orono
<br /> . Buiiding Permit Application for Maintenance / Replacement / Remodel
<br /> �i.e. �vindows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSIOh6)
<br /> �0�� Mailing Address: Permit number: ���5 � ��
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: �~/D`'l 'rj
<br /> �, StreetAddress: Received by: � � � p���
<br /> ti�, � 2750 Kelley Parkway Plan review fee: C�hQ -}(�' � ; —
<br /> t,qKFSH��t�,C' Orono, MN 55356
<br /> Total Fee: � "-��� . cZ y
<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. �rr,,'r� _3/�y/�S
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: I�/!o G��� /��c.c
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o
<br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service 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: S�e�uwmo LLG
<br /> State License# ,t3C ,s�y�3�,f' Expiration Date: 3 3i /(o
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) �,/Z • �/d/ • 33y8 (office) (o/t � y�� • �lOc�
<br /> Mailing Address: �S3 �. $�,�f E'o.sf City: W Z ZIP: ,SS"39/
<br /> Contact Person: `j�,.so,,,,. ,`l• � Applicant s: Contrac or / Homeowner (CircleOne)
<br /> Email and/or Fax: �'.�s o�. 5 µe c.�o . coe�.
<br /> �
<br /> PROPERTY OWNER INFORMATIOf�:
<br /> Name: -- �,�v�',,� � /evesa /oY£U•so�-.
<br /> Phone (day): �72 • �039 • �eoS'3
<br /> Address: �y�b ��.y ��a� City: br'o..�a ZIP: /K/ll
<br /> Email and/or Fax: ,(��v,'„� o„ �„s o� @ �,,,�,a,'l .�o,,,,,�
<br /> PROJECT INFORMATION: Overall project description: K� l�-� bo��wsc �!G' G-�-� ���-� �
<br /> Type of Project: Any earth movemen may also require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> / 15320 Minnetonka Blvd
<br /> ❑ Re-roof, cedar �'Restoration ❑Water Damage Minnetonka, MN 55345
<br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590
<br /> ��� Fax: 952-471-0682
<br /> ❑Window(s) S'cc www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project (excluding land) $ /O, o00
<br /> �
<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 information,the a lication ma not be issued.
<br /> ApplicanYs Signature: Date: ��5�!S
<br /> Owner's Signature: � Date: � S - I 5
<br /> Last Updated:January 2015
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