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City of Orona
<br /> ��������
<br /> ui ing Permifi Application for IUlaintenance f Replacement/ Remodel_ I�`; ',� „" ""'�I qNLY
<br /> (i.e, windows, doors, siding, re-roof, etc. —NO STRUCTURAL EKPANSION)
<br /> A� Marling Address: Pert7��t nu�'1b�P � �L�...
<br /> �`��V� PO Box 66 ���� �.,, .
<br /> ��: i i�.pii' �i .
<br /> Crystal Bay, MN 55323-Ob66 Date received , ': _
<br /> I�E��iVed by `,: r, ;: :;:,. :
<br /> ,� � Street AddrpSS: ,
<br /> ti�, �� z750 Kelley Parkway plari r�vl�W f e� �
<br /> � Orono,MN 55356
<br /> ,��r,slJc1� ��.1r.i ki, ,�'�'� '
<br /> r...�,,,,,._ ��Q�����'�i.:"„ )� �
<br /> Main: 952�249-46Q0 Fax: 952-249-4616 www.ci.orono�us ' U ! , ,
<br /> ,
<br /> This appllcation form must be completed in full and all required informatfon muSt e submitted,
<br /> Incamplete applicatians will be returned. (P182s9 print)
<br /> GENER�4L INFOFZMATION:
<br /> Job Site Address: (`} ' � �f �'��_�
<br /> Will this be a Parade pf Homes, Remode rs Showca ome or ot er Oisplay Home. Yes No
<br /> 1�y�s, a spodal�venr parm;r is requrred wlth Polfce aepartment snU City Gouncll approval 60 days prior fo the evgnt. Shutf�e bus servlce w11!be
<br /> requ�red uMoss appfrcant dsmonatra�es sr�ttic�enl on•sito parkirrg rs aveifeb�e. Non-perm4fed aven(s w;ll noi!�e allewed.
<br /> CdNTRACTOR/APPLiCANT INFdRMATIQN:
<br /> Name: � �-
<br /> State License # �-�g� Expiration Date: ;��,)� ��
<br /> Lead Certification Number: � ^ � �, �.�- �xpiration Date: $''����`�7(e
<br /> {for work on homes thgt were construcied prior to 78
<br /> Phone: (cell) (office)'�(�3--'JS�'�?�,��.e,w'�.,S� Y m� �
<br /> Malling Address: � !a� City: �� �IP: ��"7
<br /> ContaCt Pgtson: �� � Applicant Os: pntraCtp Homeowner (Clrcle One)
<br /> Email and/or Fax: � � �� _
<br /> t
<br /> PR�PERTY OWNER INF��tMATION:
<br /> Name: ,.�0�111 '� 1�.1�n . V �l
<br /> Phone(day): a.� f_.(�'� L-r��.�'tv�.ilr��td( f'�
<br /> Address; �ayp p�bti,,,�,� C€ty: � � Zlp; �jS,3�
<br /> Emaif andlqr Fax:
<br /> � � �
<br /> PROJECT fNF�RMATION: Overall ra'ect descri tion: } ���e
<br /> Type of Project: Any earth movement ma also require���
<br /> ❑ Do s MGWD review&permits: '
<br /> r( ) � Remodel ❑ Fire D�mage
<br /> Re-roaf, asphalt �Repeir ❑Storm Damage � Minnehaha Creek Watershed District(MCW D)
<br /> k f� Re-roof,cedar O Restoration I 15320 Minnetonka Blvd
<br /> f=1 water Damage Mlnnetonka,MN 55345
<br /> ❑ Re-roof,other s oclf Phane: 952-471-059p
<br /> f P Y) [' Siding �Othgr�(specffy) Fax: 952-471-0682
<br /> ❑Window(S) www,minnqh�haCfe�,.orq
<br /> �stima#ed Gonstruction Valuatiort of ProJect(excfuding land) $
<br /> APPLICANT ACFfNOWLEDGEM�N1':
<br /> . Agrees to providc au information required or requested by the 8uilding Department
<br /> • Certif��s that the information supplied is true and correct to the best of hlslher knowledge_ The appllcant recognizes th�t they are
<br /> solely r�spvns�ble for submitting a com�lete application befng awsre that upan failure to do so, the staff has no �Iternati�e but to
<br /> reject it untii it�s complete;
<br /> • Some or all of Che Information that you are asked to provide on this application is classlifed by Stato law as eit)ier private or
<br /> confidential. Prl+�ate data is information which generally cannot be given to thr,puplic but can be given ta the subJect of the data.
<br /> Cr�nfidential data Is inform�tian which generelly eannvt be given Eo eithgr fhe public or tt�a subject vf the dat2. Our purpose and
<br /> intanded use of this inform�tion Is to annuafly update our recards and records of other govornmental agencies required by f�w, If
<br /> ou re{use to su I the Information,the a licatlon ma nat bs issued.
<br /> �'
<br /> ApplicanYs Sign�ture:G.�� �-��� pate:
<br /> dwner's Signature: , _ Date:
<br /> l.ast Updetetl:donuary 7.016
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