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, `��'►�� �3� 1� <br /> � City of Orono � <br /> Buitding Permit Application for Maintenance I Renovation <br /> (window�, dQors, siding, re-roof, etc.} <br /> �O �` Mailing Address: <br /> ��r PQ 9ox 66 Permit number: q�b I 3 — 0 0 g J� <br /> Q �. Q Crysial 8ay� MN 55323-0066 Date received: 9- � <br /> � _� � StreefAddress,- Reoeived by: <br /> � ' �'` 275Q Kelley Parkway <br /> �g�o$� Orona, MN 55356 Plan review fee; <br /> ` 'Main: 952-249-4600 Fayc: 952-249�616 Total Fee: a j �. �G �G , <br /> www.ci.orono.mn us � <br /> This application form must be cainpleted in full and all required information must be submitted_ <br /> Incomplete ap,plications will be returned. (Please priRt) <br /> GENERpL INFORMATIQN: <br /> Job Site Address: �pQQ � 0. <br /> Wil�this be a Parade of Homes, Remodeler� owcase Home or other Display Home? Yes No <br /> yes,a special event pennit is raq�l�d with Police Deparfinenf and City Council approval 6p days prior to the evenf Shuftle bus sarvice wr(1 be <br /> iequired unless applicanf demonstrates su!/Iciern on-site parking is available. Non-permittetl evenfs wi!!not be aJ/owed, <br /> CONTRACTOR!AP,�R{LICANT IMFORMATION: <br /> Name: a.1 'Av��rSe� <br /> State License# �G130q g'3 Expiration Date: <br /> Lead Gertification Number. '✓�' 131 <br /> � �� a �'�$� " Expiration Date: Y <br /> (for wwk on homes that were consiructed priqr to 7978 <br /> Phone: (05�— a(p�.�—�O$�Q. � (office) <br /> Mailing Address: ,� „ �"� (cell) <br /> �9 a C . � c wes�t- c�ty:�osc.v;� e Z1p: ss i <br /> Contact Person: Applicant is: ntractor / Nomeowner <br /> Emaii andlor Fax: �c����eo►�e) <br /> PROPERTY OWNER �NFORMATIQN: <br /> Name: ��,�� �L��� <br /> Phone(day): <br /> Address: <br /> Ernail and/or Fax � C�ty� ZIP: <br /> PROJECT INFORMATION: <br /> Type of Project: <br /> Any earth movement may require <br /> ❑ Door(s) ❑ Remodel Q Fire Damage MCWD review 8 permits: <br /> ❑ Re-roof, as halt Minnehaha Creek Watershed District{MCWD) <br /> P ❑ Repair d Storm Damage 18202 Minnetonka B1vd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 5539i <br /> ❑ Re-roof,other(specify) ❑Sidin Phone: 952-477-0590 <br /> 9 ❑ Oiher: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek orq <br /> Overall Project Description: � _ , <br /> Estimated Construction Valuation of Pro'ect ��'� <br /> � (iexc(uding land) � �d �,p <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide aU informalion required or requested by the Building Deparhnent; <br /> • Cert�es that the information supplied is true and correct to the best of his/her knowledge. The appfica►�t recognizes that they <br /> If are solety responsible for subrnitting a complete applica6on being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until it is complete; <br /> � • Some or ail of the information that you are asked t� provide on this application is classified by State faw as either private or <br /> confidential, Private data is intarmation which generally cannot be given to ihe public but can be given to the subject of the <br /> data. Confidential data is information which generalty can�ot be given to either the public or the subject of the data. Our <br /> � purpose and intended use of this informatiorr is to annually update our records and records of other governmental agencies <br /> required bv law If u refuse to supply the in{��rm2tion,the a lication ma not be issued. <br /> Ao�licant's Sianature: � �] � � / <br /> Date: �p�� 3 <br /> -_��. <br /> Z 'd 06T9�L9TS9 3�IA213S lIW�l3d Q '8 S f� T0 =6 ETOZ ET daS <br />