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<br /> , City of Orono
<br /> Building Permit Application for Maintenance ! Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> ,�_--__�, MailingAddress: %r,�,' , � �
<br /> ���,�� PO Bax 66 Permit number. -" i -��;ri�
<br /> !%�O �� O ,` Crystal Bay, MN 55323-0066 Date received_
<br /> I�� , ��"�;�. ��i Received by:
<br /> 9��� Street Rddress
<br /> '�\� ` � �"� Y Y Plan review fee:
<br /> ,�,� `��, �ti 2750 Kelle Parkwa '
<br /> �?�Es�o$�/ Orono, MN 55356 ;, „
<br /> �=__=� Totat Fee: .�:�� �� ;.-� , ���,
<br /> Main: 952-249-4600 Fax: 952-24911616 v,rvvw.ci.arono.mn.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incamplete applications will be returned. (Please print)
<br /> GENERAL[NFORMATION:
<br /> Job Site Address: �L�J-�� ���-� � � � ������c�, �,�P�`
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ❑ No
<br /> If yes,a specia!event permit is required with Po%ce Departmenf and Ci'ry Counci!approval 60 days prror fo the event. Shuttle bus servrce will be
<br /> reguired unless applicant demonstrates s�cient on-site parldng is available. Non-permitted events wil!not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: .�J�-'�i�-�r�- �"r i� ��-=i=�,.�`�"_.5
<br /> Shate License# �'; `�� ',j Expiration Date: `y -j�'% - ` �.�%„�
<br /> ; �
<br /> � Lead Certificativn Number: ,�'f �,�,g. Expiraiion Date:
<br /> (for work on homes thaf were constru�or to 9978
<br /> Phone: �;x„� /-- �'�-�`,�y (office� �' ,� .� ���`c j_ '7�'„s':' {cell)
<br /> Mailing Address: r�j� �y T v,n �,¢. ,c� ,� Cify: .-�j�'r,,.-..� ZIP: �'
<br /> Contact Person: � ,,�� Applicant is: Contractor / Homeowner (CtrGe One)
<br /> Email and/or Fax: ��-�" -��fj.r ,� ,? �y- "? �
<br /> PROPERTY OWNER 1NFORMATION:
<br /> Name: � �;`_�;e-�`.�. �'�';:,� c�c�-�
<br /> Phone{day):
<br /> Address: , �-�,-,�-�_ City: ZIP:
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require ;
<br /> ❑ Door(s) ❑ Remode( ❑ Fire Damage MCWD review S�permits:
<br /> Mi�nehaha Creek Watershed District(MCWD)
<br /> e-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> ❑Re-roof, cedar ❑ Restoration ❑Water Damage �eephaven, MN 55391 ,
<br /> Phone: 952�71-0590 i
<br /> ❑Re-roof, other�specify) ❑Siding ❑Other. (sp2afy) Fax: 952-471-0682 �
<br /> www.rninnehahacreel<.ora i
<br /> ❑Window(s) r
<br /> Overal! Project Description: � °+� �=A.�"= - v,�W
<br /> Estimated Construction Valuation of Project(excluding land) $ �' �� �
<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 carrect to the best of his/her knowledge. The applicant recognizes that they
<br /> are solely responsible for subrnitting 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 provid2 on this application is classified by State law as either private or
<br /> confidential. Private data is irtformation 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 of this information is to annually update our records and rec�rds of othpr governmPntal a�enr..ies
<br /> re uired b law. If ou refuse to thejc� rma ,the a {ication ma not be issued.
<br /> �,_,,,,�. µ .,�._._.---„_._,_..._..... _ .
<br /> Applicant's Signature: -'�„�,�.�`1 °•��— Date: ��� / � ����
<br /> ,�
<br /> Last Updated: 08-09-2011
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