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���y of �ro�o
<br /> • Buif�ing �errnit Appfica�io� for Maintenance / Renovation
<br /> (windows, doors, siding, re-ro�f, etc.)
<br /> Mailing Address: I /�� �
<br /> /d� PO Box 6o i Permit number.
<br /> /o Q \ Crystal Bay, MN 55323-0066 Date received: ��9;�
<br /> 1 �' !
<br /> �a ( � -� �, ; Streef Address: Received by: p4,�,
<br /> \�r� ; ,� ��/ 2750 Kelley Parkway Pfan review fee:
<br /> \L9kEsxo4"� 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 compfeted in full and all required information must be submitted.
<br /> incompfete appficati s will be returrre�, (Please int) ����/
<br /> GENERAL INFORMATION: � � I/V�L/
<br /> Job Site Address:
<br /> Will this be a Parade of Homes, Remodefers Showcase or other Display Home? ❑ Yes ❑ No
<br /> !f yes, a spec�a/event permit is required with Pofice Deparrment and City Counci/approval 60 days prior to fhe event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed.
<br /> CONTRACTOR/AP IC�NT INF RM T�Cj11�:
<br /> Name: /
<br /> � ��f� �-� /;.-,._
<br /> State License # Expiration Qate:
<br /> Lead Certificafion Number: Expiration Date:
<br /> (for work on homes thaf were constructed prior to 1978
<br /> Phone: (office) (cell)
<br /> Maifing Address: � � City: ZIP:
<br /> Contact Person: Appficant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER JA�O�MAT1qN: �� , �,
<br /> Name: �-��� < ���'l�� :���--
<br /> Phone(day): �'� �� >�.,�' _�'�s r �-- .
<br /> Address: � -� ' -
<br /> '�__> <_�f� ���'/'c�w��; !�z ,, _� City: C����.,�r ZIP: `�),s' S'�
<br /> Email and/or Fax �"�,,��. �s�����, �: �� { � � � �
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) �(�Remodel MCWD review&permits:
<br /> ❑ Fire Damage
<br /> ❑ Re-roof, asphalt ❑ Re air � Minnehaha Creek Watershed District(MCWD}
<br /> p ❑ Sform Qamage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> ❑ Re-roof, other(specify) ❑ Sidin Phone: 952-471-0590
<br /> g ❑ Other: (specify) � Fax: 952-471-0682
<br /> ❑Window(s) www.rninnehahacreek.orq
<br /> Overall Project Description: t ,,, ,.� � � '� — - �_
<br /> _ .ti__ . ., � _ - - -�,__ �
<br /> Estimated Construction Vafuation of Project(excluciing fand) $ ,fj �r,. ,;,�,, , � - --
<br /> 1 L_'r'��_ r.,"c ,- 1 L ��;i _�,
<br /> APPLlCANT ACKNOWLEDGEMENT: ���� �� �
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The appficant recognizes that they
<br /> are solely responsible for submitting a compfete application being aware that upon failure to do so, the staff has no alternative
<br /> but to reject it until it is complete;
<br /> • Some or all of the information that you are asked to provide on this appiication is classified by State law as either private or
<br /> confideniial. Private data is information which generally cannot be given to the public but can be qiven to the subject of the
<br /> data. Confidential data is inTormafion which ge erall�aannot be given to either the public or the subject of the data. Our
<br /> I purpose and intended use of this information to anr�ally update our records and records of other govemmental agE+ncies
<br /> required b law. If ou refuse to su I the i orrxfation.tiye'ao fication ma not be issued.
<br /> � ,
<br /> Appficant's Signature: / i � � Date: ,f-- / �, _
<br /> Last Updated: 08-09-2011
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