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. , <br /> � City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> O ,;:...:�. .. ' .: .,, <br /> g' �l' ai/P0 B x 86� � �... �:.. :...�,,;., . :,:.. �;�-.I;,I, .,. <br /> ;PecrniL:riUrri6er ., `., � l';• ' `;:ii <br /> � Crystal Ba , MN 55323-0066 ` � � <br /> � y 'Date':�eceived:.. �i: . <br /> ' <br /> ; � <br /> ,. <br /> T <br /> ..���.�.:' <br /> �: <br /> St�et Addr�ss: Reoeived by::•.;':: , `'.•::...`;' <br /> ��` o� 2750 Kslley Parkway ` ; <br /> .,.:... : <br /> � Plan;rev,iew;.fee:`:''': :;r `„ <br /> �`xEs�o¢ Orono, MN 55356 <br /> Ma;n: 952-2 'Tota'l"Fee:;:' .: ,:.,.;`,`�; <.,,:�.: :..,/;.:>>;�, '.: ;.�.;:',, <br /> 49-4B00 Fax: 952-249-4616 uvww.ci,orono.mn us � • � <br /> , ... <br /> : ,... „ .. ..:.:: :......1�';'>.:;�:. ':':.:.,.,;,; <br /> This application form must be Completed in full and all �equired Information must be submitted. ` <br /> Incomplete applications will Be returned. (P/ease print) <br /> GENERqL INFORMA710N: ' <br /> Job Site Address: 3 ER � �, N <br /> Will this be a Parade of Homes,Remodelers Showcas�Home or other Display Home? Yes No <br /> �yres,a specia!event pe�mit is requlrpd with Police DepaRment and City Council appro►al 60 days p/ior to the event Shuttle bus saniice wlll be <br /> r�quired unless app/kvnt demanstrates sulTicient on-srte perking ls aVaila6/e. Non-permi(fied events wil!not be a/lowed_ <br /> coNTRaCTOR i APP�iCANr INF�RnnATION: <br /> NBme: �Qo �}L ��pf'/N( <br /> State License# a o�-�$� �a Expiration Date: <br /> Lead Certification Number: ' 3 °� <br /> (for work on homes�ar were constructed prior f�n 1978 E���tion Date: <br /> Phon�: 3 -a9s-o,�"�O (office) 763--��'/- / � (cell <br /> MailingAddress: �y7 �p�,,a soN � <br /> Contact('erson: � C�tY'Ma icEt-�v Z1P: S536oZ <br /> S�� ti► �6i�S�nl Applicant is: ontra or / Homeowner �c�.��eo�a� <br /> Email snd/or Fax: `,,,� �ro 1 reo�m � Co <br /> PROPERTY QWNER 1NFORMATION; <br /> Name� �R` _ <br /> Phone da u � <br /> ( v)� �I a-3 �9a�3 <br /> Address: 5��,E � ovE <br /> Email and/or Fax ���'� Z1P: <br /> PROJECT INFORMATION: <br /> 7ype of Project <br /> ' Any earth movement may requlre <br /> ❑Door(s) ❑ Remodel ❑ Fire Damage MCWp review�permits; <br /> L�l7 Re-roof,asphalt ❑Rapair Minnehaha Cr�eek Watershed District(MCWD) <br /> ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑R�roof, other(spacify) ❑Siding ❑Othar,(specify) PFax: �g52�1 06820 <br /> ❑Window(s) www.minn hahacreek.or <br /> Over�11 Project Description: ,eE-R6oF <br /> Estimated Construction Valuatlon of Project(excluding land) $ Q 3 S7� �� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all informatio�required or rnquestad by the Building Department; <br /> � • Certifies that the informaYion supplied is true and correct to the best of his/her knowledge. The applicarrt recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until it is complete; <br /> • Some or all of the infoRnation that you are asked to provide on this applicaUon is Gassified by State law as either private or <br /> confidantial. 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 of this information is to ennually update our records and records of other govemmenial agencies <br /> r uired b law_ If ou refuse to su I the information;the a lication ma not be issued. <br /> Applicant's Signature: y/ay ', <br /> Date: <br /> last Updated: 0&09-2011 • <br />