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<br /> � City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
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<br /> ;PecrniL:riUrri6er ., `., � l';• ' `;:ii
<br /> � Crystal Ba , MN 55323-0066 ` � �
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<br /> St�et Addr�ss: Reoeived by::•.;':: , `'.•::...`;'
<br /> ��` o� 2750 Kslley Parkway ` ;
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<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 � • �
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<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 •
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