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. � ��� a�r� <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: �l G�-�� (1 / <br /> O.¢,�,j�.O PO Box 66 p <br /> Crystal Bay, MN 55323-0066 Date received: ` - '�� �- <br /> a �� ,�' �,� Street Address: Received by: e�� � <br /> '�',�,t % x^y �ti�' 2750 Kelley Parkway Plan review fe <br /> *v Orono, MN 55356 <br /> "��Ko4 �� � ��.75 <br /> == Total Fee: <br /> Main: 952-249�600 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. <br /> Incomplete applic jons will be ret�ed. (Ple se prir� <br /> GENERAL INFORMATION: � I <br /> Job Site Address: � ��(1 �.� �ti�. �` �� � r:�.r-t'i�� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes �LQ <br /> lf 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 /> . . <br /> Name: ,�� � ! ,�� �,� <br /> State License# 2 �� ,�; � � S��y _ Expiration Date: � � C / S <br /> Lead Certification Number: �/� d � 13 � �� � �� Expiration Date: �T� � � y <br /> (for work on homes that were constiucted prior to 1 78 <br /> Phone: �� _ � �� -.. (office) �z '- 7Cp ���L� �=�.._ (cell) <br /> Mailing Address: � � ' �— j� : � �, City: " ZIP: .y�`;a <br /> Contact Person: ��� �'� lZ_,�,� ��,_ �� � Applicant is: ontractor Homeowner (Circle One) <br /> Email and/or Fax: � ! '� <br /> ( '� �.> � <br /> PROPERTY OWNER INFORMATION:,1 � � �E,Yi �� <br /> Name: �G� ��. � _ <br /> Phone (day): <br /> Address: J �-j �D d.d) ;� l. ra.�' t��' ��rl C��� C�/C7 �-v ZIP: � sc� � ( <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits: <br /> (�.Door(s) emodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof, other(speciiy) ❑Siding �.Other: {speci •� Fax: 952-471-0682 <br /> �Window(s) >i w,;' i,. �.minnehahacreek orq <br /> Overall Project Description: ��'- L - �1 j/��G� (�yK'� � CQ� <br /> Estimated Construction Valu n of Pr �ect xcluding land) a �'Q � �r- <br /> �'�''' fl"�-S �- /` � ''�' "' �-,��;,o✓ �2'tfi b <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 submitting 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 dassified by State law as either private or <br /> confidential. Private data is informatioh which ge ally nnot e given to the public but can be given to the subject of the <br /> data. Confidential data is information vrhi gen ally nnot given to either the public or the subject of the data. Our <br /> purpose and intendedlUse of this inforr� on is an ually ' ate our records and records of other governmental agencies <br /> r uired b law. If ,du refuse to su I , info ati the lication ma not be issued. <br /> � � ' -- <br /> ApplicanYs Signature: � � ' ""` Date: ��,z � --� �_ <br /> Last Updated: 08-09-2011 <br />