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, 4 City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> �O� MailingAddress: Permitnumber: p���� -'�/�7
<br /> O PO Box 66 _
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> Street Address: Received by:
<br /> y ` 2750 Kelley Parkway Plan review fee:
<br /> F G
<br /> t �, Orono, MN 55356 �f
<br /> �'�ESHO4 I/�� / '
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.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: , (_ , . �- . � . ,
<br /> Job Site Address: ;� ;; � f"�`'� ��l�l��' ��C� ���' s��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No
<br /> If yes, a specia/event permif is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR I APPLICANT INFORMATION:
<br /> Name: j1//�f k,� �� �s l d,. ;.��( ,�,-,
<br /> State License# �;� ,�,�,,_;�, �,-, Expiration Date: �� - �/ _ j c
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) (,, ; � -- �} y �; �-��� r`i (office) (� j—� �f ��� �,ti
<br /> �
<br /> Mailing Address: c/c/� Z cr, sf.c;;-/ �-C . �_ ��-� >v-� City: %�;���' �i'�,�„,- ZIP: S'�.j 5 �
<br /> r� �z
<br /> Contact Person: S�i-, ., C�,n n_e� Applicant is: �C-#or / Homeowner (Cirde One)
<br /> Email and/or Fax: '��s - y � j-��vv
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �`',t. r.,, - -�' %z J���' �
<br /> Phone (day): 7�,3_��� -�Z c� �-..� �
<br /> AddreSS: � k v i'c'r_n.�i iL� ✓'(.�'l Clty: Lt/f ,. �r f�_. ZIP: J _� � `�/
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> ,�te-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590
<br /> J l�,�Y, Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<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 correct to the best of his/her knowledge. The applicant recognizes that they are
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to
<br /> reject it until it is complete;
<br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or
<br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data.
<br /> Confidential data is information whicF�generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this inforrr�tio is,ta annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I th `rifor f n„th a lication ma not be issued.
<br /> Applicant's Signature: �I,Z�-_ �����'�"�� Date: �J � y •� �S
<br /> Owner's Signature: Date:
<br /> Last Updated: 03/06/2013
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