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. F'bm:Hunerbe�g Construction 555 555 5555 07�26/20�3 10:45 #077 P.00I /003 <br /> U <br /> C/i��K% <br /> ���'�'� <br /> City of Orono �-� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.} <br /> OA,. Marling Address; Permit number. v7���j��J <br /> � <VO PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: —2--g��j <br /> a ,, <br /> Street Address,- Received by: <br /> ti G� 2750 Kelley Parkway Plan review fee: <br /> F Orona, MN 55356 <br /> t�kESHO�`ti <br /> 7otal Fee. �,/� ��j <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. (Please print) <br /> GENERAL INFORMATION: <br /> JobSiteAddress: �1t7c�C �oirr,��r� sidc, Llr- 1N �;:r,n�;���� tn,�' ti.�35�,> <br /> Will this be a Parade of Homes, Remodel rs Showcase Hom or other Display Home? ❑Yes No <br /> If yes,a specia!event permit is required wrth Police Depanment 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 avai/able. Non-permitted events will not be allowed <br /> CONTRACTOR/APPLICANT INFORMA710N: <br /> Name: EJu��i-(��;-c� L�c�nsfruct��n L�tm�anu <br /> State License# f;c�c:3w��3 Expiration Date: z:;��;Jzc;y <br /> Lead Certification Number; j.��,-..�,t,SC,;�_1 Expiration Date: c413c�;;�:a,` <br /> (for work on homes that were consfructed prior to 1978 <br /> Phone: (ceU) 7�„�-�3;�.r�q�1�� (office) �74:���i��-3'���� <br /> Mailing Address: Iiic�, �1��/���nu� �y'"c�-F� CitY �'a-ic C-rc;ro ZIP: �.��-,��� <br /> ContactPerson: �el�n 11zinCr(��rG Applicantis: ontracEor` 1 Homeowner (CirclaOne) <br /> Emailand/orFax: :���hnj� �f�l.il�l'Y��fr.GCn� � �71�3-ti1,3 ��^�+L,> <br /> PROPER7Y OWNER INFORMA710N: <br /> Name: �r�,c-haci N' �a,��rd and �c�r�! R �a;r<� <br /> Phone(day): <br /> Address: �'teC L'�•�uafrr.�a�c1e Qr, Vv City: ,�.cr7u ��Ke_ ZiP: .5�3��,:. <br /> Email and/or Fax: � � <br /> PROJECTINFORMATION: Overall roectdescription: �iJr��d�t� �,ia�rn>e��t �n� .Sh;cecliC v,rs� <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) ❑Remodel ❑Fire Damage <br /> MCWD review 8�permits: <br /> ❑ Re-roof,asphalt �Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Demage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) ❑Siding ❑Other:(specify} Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Q Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ �e 9�����>r <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 are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it untif it is complete; <br /> • Some or afl 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 data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I t rm ki ,t a lication ma not be issued. <br /> ApplicanYs Signature. Date: _ �7�Z-1���� <br /> Owner's Signature: . Date; <br /> Last Updated:03/06/2013 <br />