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� � City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> �—�A, Mailing Address: Permit number:
<br /> ;/ i��`YO PO Box 66
<br /> r�
<br /> ' Crystal Bay, MN 55323-0066 Date received:
<br /> 1 � Street Address: Received by:
<br /> � � � 2750 Kelle Parkwa
<br /> '`y :/ Y Y Plan review fee:
<br /> `�c� , �.`-' Orono, MN 55356
<br /> ��SHv�
<br /> __ Total Fee:
<br /> Main: 952-249�600 Fax: 952-249-4616 'wwv�r.v ci.o�:����:.; :nn.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: �'�`nt�'r7" r� = v�� - //� -.1-3 _�i _ ��:� �
<br /> Job Site Address: %/ �'p .����Z �a`✓��J , /�-i t-�v!�� �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes (�lo
<br /> If yes,a specia/event permit is required with Police Department and City Council approva!60 days prior to the event. Shuttle bus service wil!be
<br /> required unless appticant demonstrates sufficient on-site parking is available. Non-permitted events wi11 not 6e albwed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �i,m.t-C ��%c-��.v� �:���`�`�'�
<br /> State License# ���'�3'i� i� Expiration Date: �3 �� ��;;�
<br /> Lead Certification Number: �.�� ���v7c� ;2 Expiration Date: G� � _��,;
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) �6i� ) ��� -- �S-G G (office) �j�j) %��-C G� �
<br /> Mailing Address: /���v �,,, s-S.- City: ��yh,,�,,T,� ziP: s s-yy G
<br /> Contact Person: ,�F�� i3, ����f�f.���.f,,, Applicant is: ontrac o / Homeowner �c�rc►eo�e�
<br /> Email and/or Fax: ,�-�i<<�/�i�vE'�%✓ ,L'L'� /f.-r.-�-�z/3.:��,o..-- G c.�-._frrx_ . f�-----�_
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �'i�-c% L f,��� �
<br /> Phone(day): 9 s"�c - y-7�Z - s-y s�i
<br /> Address: %� yo �,�� ,l1�,�-r� CitY: �'��,,.,!� ZIP_ .SS� S G y
<br /> Emaif and/or Fax:
<br /> iPf�-+-+vs-rc f iP�/'�r�s'Gr` �fj! /�-'�o�����e7�... �f r/
<br /> PR�I IC�`T IAIC/1�MAT1/'1W. rl.,,....n .........,a.�..,.,,�:
<br /> tlOn: �/� � G=�.rJ i �Ts�i�f.v rS -i°!� ,9�z.� s':r,N�� s",zr <�f,,.,^-L_�
<br /> rYF Any eaRh movement may also require
<br /> ❑ � �e Damage
<br /> MCWD review&permits:
<br /> ❑ ( L�� `c;� � ; , orm Dama e Minnehaha Creek Watershed District(MCWD)
<br /> ` ��� 9 18202 Minnetonka Blvd
<br /> ❑ � ' � � ater Damage Deephaven, MN 55391
<br /> `' � �` --F=-- „ � �;'. � � � �) Phone: 952-471-0590
<br /> ❑ ' � her: s ci Fax: 952-471-0682
<br /> _ ��'�-��:z � L �1`�;��r�c� � ��t , �,v,a,��:�.�r:irnehahacreek.orq
<br /> Es1 ` `� uding land) $ /7�, Sov
<br /> AP
<br /> • �d by the Building Department;
<br /> • �ect to the best of hislher knowledge. The applicant recognizes that they are
<br /> ion being aware that upon failure to do so, the staff has no alternative but to
<br /> • :o provide on this application is Gassified by State Iaw as either private or
<br /> ally cannot be given to the public but can be given to the subject of the data.
<br /> iot 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 agenaes required by law. If
<br /> ou refuse to su 1 the information,the a lication ma not be issued.
<br /> Applicant's Signature: ��.� /S�,�,.I..GG�.-- Date: �� �:� �S
<br /> Owner's Signature: Date:
<br /> Last Updated:03/06/2013
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