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06/11/2012 13:58 FAX I�001/001 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, sidin , re-roof, etc.) <br /> —�� Mailing Address; Permlt number, a0�a- - �OS/5 <br /> 0.�,�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: ���� /?i <br /> s, Str�et Address: Received by: <br /> ��, ' � 2750 Kelley Parkway Plan review fee: <br /> $ Orono, MN 55358 <br /> � H� <br /> —•— Total Fae: <br /> Maln� 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> Thls appllcation form must be completed in full and all required information must be submltted. <br /> Incomplete applications will be returned. (Please print) <br /> Job Slt�e Address�ATION: �� S <br /> � �,. � .�S ��y/ <br /> WIII thls be a Pa�ade of Homes, Remodelers 8 owc sa e Home ar othe�Diaplay Home� Yes � o <br /> !/yss,a speciel s►rent permit la requlred with Pollce Depe►tment end Clty Cflunci!epprove160 deys prior to the event. Shutfle bus servica wil!be <br /> requiiad unless appllcant demor�st�afes sulBclent on-sif�parking ia avelleble, Nony�ermifted evenfs will not De ellowed. <br /> CON7RACTOR I APPLI AN INFOR TI <br /> Name: ,�.d � :J <br /> State License# Explratlon Date: /; <br /> Lead Certification Number: Expiration Date; <br /> (foi woik on homes that woere co�structed pdor to 9978 <br /> Phone: -8 ' (o�ce) (cell) <br /> Mailing Address: � . ¢-� ,� Cit : �; ZIP: S rj (� `� <br /> Contact Person: , �� , , �e�,� �.,� Applicant is; Contra / Homeowner (Clrele Ona� <br /> Email end/or Fax: ;- �51,�,�,,' ,1.. r,,,�i; ,� . �o w� <br /> PROPERTY OWNER INFORMATION: <br /> Neme: , <br /> Phone(day): <br /> Address: City_ ZIP: <br /> Email andlor Fax <br /> PROJECT INFORMATION: <br /> Type of ProJecL Any earth movement may requlre <br /> MCWD review 8 permita: <br /> ❑Door(s) ❑ Remodel ❑ Fire Damage Minneheha Creek Watershed District(MCWD) <br /> ❑Re-�oof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonke Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Weter Demage Deephaven,MN 55381 <br /> Phone: A52-471-0580 <br /> �e-roof,othe�(specl ❑Sldlnp ❑Othe�(specify) Fax: 952-471-0682 <br /> p www.minnehahacreek.or� <br /> ���v�.y���►�{�. IC.ao ❑Window(s) <br /> Overall Pro ect DescrlpUon: � � � t <br /> Estlmated Constructlon Valuatlon o roJect(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provlde all inFormatlon required or requested by the Building Department; <br /> . Certifies ihat the informatlon supplled ia Uue end conect to the best of his/her knowledge. The appllcant recognlzes that they <br /> are solely responsible for submilting a complete applicetion being ewere thet upon feilure to do so, the staff has no alternative <br /> but to reject It untll it is complete; <br /> • Some or all of the information that you are asked to provide on thia application is classified by State law as either private or <br /> confidential. Private data is information which ge�erelly eannot be give� to the public but can be given to the subjed of the <br /> data. Confldential data is information which generally cannot be given to elther the public or the subject of the data. Our <br /> purpose end Intended use of thia information is to annually update our records and records of othe� govemmental agencies <br /> re ulned b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: �,��/,� � Date: —�/' �� <br /> LaslUpdaled; 08-08-2011 <br />