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City of Orono
<br /> �Building Permit Application for Maintenance / Renovation
<br /> � (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> 4v 0,� PO Box 66
<br /> �� �
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> �i '� Received b
<br /> a ��,;�:� �, Street Address: y�
<br /> �'� � � s'�s� ti 2750 Kelle Parkwa
<br /> � Y Y Plan review fee:
<br /> t9�sxo�'`� Orono, MN 55356
<br /> Total Fee:
<br /> Main: 952-249-4600 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 applications will be returned. (P/ease print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: "�_- �-(S C p�;,,,�r S;���c� �r'.
<br /> Will this be a Parade of Homes, Remodele�s'Showcase Home or other Display Home? ❑ Yes No
<br /> If 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 su�cient on-site parking is available. Non-permitted events wil!not be allowed.
<br /> CONTRACTOR/AP LICANT INFORMATION:
<br /> Name: ( �r ��„�s�-/L't- �a.�
<br /> State License# � " j 5�� Expiration Date: �-3 (-� l,'
<br /> Lead Certification Number: R_� �' 7Z��L _ 1Z'�>173 Expiration Date: �-2,�- � "'�
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: '���- y'�Lf- � ?GC:- (office) �; �2-"�� C% — �,�, (cell)
<br /> Mailing Address: S � S ,,�� �;�1 � Lr City: �`�t c- lc ��,,;,� ZIP:�>�3 ���
<br /> Contact Person: ���(,� C(^�„� .���„ Applicant is: ontractor / Homeowner (CircleOne)
<br /> Email and/or Fax: ���,��; ���(��-� � ,�..e���� . �;,,�,.�
<br /> PROPERTY OWNE INFORM TIQ N:
<br /> Name: ��,. ti�..�� }��7r:��v^�� �j � � � �
<br /> Phone (day): ���-y_� —Gjt��y �� �
<br /> Address: �`�S'Ca,,,.�f� �,� - �`. City:�..`,� LK� ZIP: S�j��� �•
<br /> Email and/or Fax --
<br /> PROJECT INFORMATION:
<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 ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> �Re-roof,other s eci Phone: 952-471-0590
<br /> ( p fy) ❑ Siding �Other: (specify) Fax: 952-471-0682
<br /> �-� l� ❑Window(s) R�.�.�"��'rfti;r..,S'� ~ �.minnehahacreek.orq
<br /> Overall Project Description:�=,�fjL�,,�,r,- �;„�-, �., `�.}�;��t;� ��^� 5.���.`�
<br /> tstimateci Gonstruction Valuation ofi'Project(excluding land) $ 1c� b�U
<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 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 which generally cannot be given to either the public or the subject of the data. Our
<br /> purpose and intended use this information is to annually update our records and records of other governmental agencies
<br /> re uired b law. If ou ref s to u I the information,the a lication ma not be issued.
<br /> ApplicanYs Signature: Date: �Z�" � Z
<br /> Last Updated: 08-09-2011
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