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Mar 17 14 03: 48p Victor & Kathy Barke 507-625-3343 p. 2 <br /> � s lyv` r�-1`�' <br /> 3'� <br /> City of Orono <br /> Buiiding Permit Appiication for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O�O Mar1rP0 Boxr66� Permitnumber. o?��5�'-6� a,oZl <br /> Crystal Bay,MN 55323-006fi Date received: 3 ""/ —/ <br /> � � StreetAddress: Received by: <br /> 2750 Kelley Parkway <br /> y�tq'��SHO��G` Orono, MN 55356 p�an review fee: <br /> - Total fee: 1 � <br /> Main: 952-249-46Q0 Fax: 952-249-4616 www.ci.orono.mn.us (X�• 5 S <br /> This application form must be completed in fufl and all required information must be submitted. <br /> Incomplete applications wi11 be returned. (Please print) <br /> GENERAL 1NFORMATION: <br /> Job Site Address �f� `'s ,� ��� <br /> Wilt this be a Parade of Nomes, Remodelers Showcase Home or other Display Nome? ❑Yes ❑No <br /> If yes,a specia!event permit is required with Police Departmant and Cify Counci!approval 60 days prior to the event. Shutile bus service wrll be <br /> required unless appliCant demonstrafes su�cient on-site parking is avarlabla. Non-permitted events will not be aUowed. <br /> CONTRACTOR 1 APPLICANT INFORMATiON: <br /> Name: C.i�r�'�{�x,� ��Ci;�.Cln��l,� ,�.����.��r� <br /> State License# �C 14��-7� Expiration Date: �3- 3} <br /> Lead Certification Number: � �-r- �v J D i--, - i Expiration Date: -�_ �� - l,o <br /> (for work on homes thaf were consfrucied prior fo i9r8 <br /> Phone: (cell) (office) � _ 2" - O SQU <br /> MailingAddress: 5�}oC�y ,r�n ��,.r� City: m;�nl�c�t� ZIP: v� ppI <br /> Contacf Person: � 1 r�c.i c� �i��o�� �-aS Applicant is: Contracfo`r ! Homeowner (Clrcle One) <br /> Email and/or Fax: -�;�� ci c� � CYI�/C C)m D 4�b�.7�cl�n"`�� C.crm <br /> PROPERTY OWNER INFORMATION: <br /> Name: �, � <br /> Phone(day): (y ��- -'�� - �1 l a <br /> Address: l�� �� C�-L�b i,r,� CitY'`�}y ZIP• �j r °�s� <br /> Email and/or Fax: ��c���n `' � <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type of Project; Any earth movement may also require <br /> ❑Door(s} ❑Remodel ❑ Fire Damage MCWD review 8�permits: <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,cedar ❑Restoration 18202 Minnetonka Blvd <br /> ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(specify) ❑Siding �]Other�(specify) Phone: 952-471-0590 <br /> Fax: 952-471-Ofi82 <br /> � ❑Window(s)� c����c,n.����; ••- ,h�minnehahacreek orq I <br /> �,� _�1 <br /> Estimated Construction Valuation of Project(excluding land) $ ��o `-- <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 hisJher knowfedge. 7he applicant recognizes that they are <br /> solely responsible for submitting a complete application beiny aware that upon faifure to do so, the staff has no alternative 6ut to <br /> reject it until it is complete; <br /> • 5ome 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 generapy cannot be glven 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 h information,the a lication ma not be issued. <br /> ApplicanYs Signature: � � CQ�,F_�� Date: �(�,r(.��, vZ�)� <br /> Owner's Signature: Date: � <br /> Last Updated:03l06/2013 <br />