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City of Orono �
<br /> ,
<br /> Building Permit Application for Maintenance / Renovafion �-,
<br /> ' (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address:
<br /> /'�v 0,� PO Box 66 Permit number:
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> O ���"��'r� O I Received b
<br /> a � � : :�.,,_ s,� Street Address: y�
<br /> �'� •'�'�,_ �ti� 2750 Kelley Parkway Plan review fee:
<br /> L�sk ��4� Orono, MN 55356
<br /> Esxo
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This appfication form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (P/ease print)
<br /> GENERAL INFORMATION: ,�
<br /> Job Site Address: ��,,��'7 j�c_y' �;�,� i�����
<br /> Will this be a Parade of Homes, Remodel rs Showcase Home or other Display Home? ❑ Yes .�}No
<br /> If yes,a special event permit is requrred with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be
<br /> required unless appJicant demonstrates sufficienE on-site parking rs available. Non-permitted events wil!not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> � i
<br /> Name: �1E-�����.6 r. �-�s W,w,�v.,�s � -..�..f ��;.,r�>, " i���
<br /> State License# r��� �c���U� E piratio Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were construcfed prior to 1978
<br /> Phone: �-�-jy��� � (office) (cell)
<br /> Mailing Address: �-s�n �u -c 15z-.� ( . Cit : .. f ZIP: �
<br /> �( v L:.;,���r->---, S�3 %C�
<br /> Contact Person: ���� �/l�d(G, Applicant is: Contractor Homeowner (Circle One)
<br /> Emailand/orFax: \j,t�,,,,��c(� (,� v�.�,�,J_c��
<br /> �:,::- _._____
<br /> /
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ' ��
<br /> ��r�� �i-•i-v�✓ln[1�
<br /> Phone (day): j 'j Z - 7_7('� - 9�> � -
<br /> Address � �' �, ,,,z� ��, � City: � �� � ZIP: 5 j'��=
<br /> � � v �
<br /> Email and/or Fax � '
<br /> PROJECT INFORMATION: �1 �
<br /> Type of Project: + Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel � ❑ Fire Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof, asphalt ❑ Repair T,� ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration `� ❑Water Damage Deephaven, MN 55391
<br /> ❑ Re-roof, other s eci Phone: 952-471-Q590
<br /> ( p fy) ❑ Sid'ng / ❑ Other: (specify} Fax: 952-471-0682
<br /> Vindow(s) � , www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding landj $ - `=
<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
<br /> are solely responsible for submitfing a complete 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 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
<br /> data. Confidential data is information whic Ily ot be given to either the public or the subject of the data. Our
<br /> purpose and intended use of this in ation is t nnuall update our records and records of other governmental agencies
<br /> re uired b law. If ou refuse to I the infor ation fion ma not be issued.
<br />� /� ,
<br /> ApplicanYs Signature: Date: �/—���—�� �
<br /> Last Updated: 08-09-2011
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