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<br /> City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Oniy windows, doors, siding, re-roof, etc.)
<br /> ��A, Mailing Address: _D�
<br /> 'VO PO Box 66 Permit number: �
<br /> Crystai Bay, MN 55323-0066 � Date received: /0 30 ! '
<br /> ,
<br /> ,� , Street Address: �� Received by:
<br /> 'Y�, G� 2750 Keiley Parkway � � Plan review fee: .
<br /> `�k£SH��� Orono, MN 55356 1 ',`��/� �
<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 wiil be returned. (Please print)
<br /> GENERAL INFORMATION: , / ^� � �-�, ,, , �,
<br /> Job Site Address: (a �I -�j �' ���j„� �" �,{_��
<br /> �::��- t: �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No
<br /> /f yes,a specia/event permit is required with Police Department and City Counci/approva!60 days prior to the event. Shuttle bus service wi//be
<br /> required un/ess applicant demonstrates s�cient on-site parking is available. Non-pemritfed events wid nof be albwed.
<br /> CONTRACTOR/APPLICANT INFQRMATION: �; � -
<br /> Name: �•-'� � �=��:�• :s':,� .,,i �� j�•;a J.`A:,, , f:
<br /> State License# " �.° � Expiration Date: ,� ' `> '���
<br /> Lead Certification Number: ��,=-� G(.�°"? � .,, Expiration Date: 1�����--
<br /> (foi work on homes that were cRnstructed pria�to 1978
<br /> Phone: (cell) ` � � �' . , � � � , �
<br /> � + � ,-����,. ���,�� �� (o�ce) e' �_��- � `�ti�.._ �,! �. c �r °::�
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<br /> Mailing Address: � �? k t`� '' R-; ^ , `, . ty: ,1��-��<�.�T,� ��.r� c1
<br /> v..s �r�... " ` � ; ¢.,.._,�� ,a� y�� � Ci . :�. �� ZIP: � +..
<br /> Contact Person: `�' �,,-{.', �.1���� ,` , pp icant is: � Contractor'? / Homeowner
<br /> -*-- � A I �, (circle one)
<br /> Email and/or Fax: � � � ` 4 t' . � •� , > �F < ,�"°"��--''
<br /> 1' :t'i � � , t"�'"Q� �`�c_,�`�' .� � . ,`
<br /> PROPERTY OWNER I ORMA.TION
<br /> ; � t�`f � �,,
<br /> Name: '�j L., �.�i ; ..��a�,� �, c, � ,e ... ! .'� �'a� r' �
<br /> Phone(day): z
<br /> Address ���G �;.» .� ,t�l 6. �e ,,`;, x_r_: 1�,� City: �.r��� u�:' .:, ZIP:
<br /> Emai!and/or Fax:
<br /> �
<br /> � ) w , �:
<br /> PROJECT INFORMATION: Overall ro'ectdescri tion:r��''r " �` ''-� :.`• . � ' � �;� �?c, - � " ', 1 '�:i'r ''�, `' ° "f�,
<br /> Type of Project: Any earth movement may also req ire
<br /> ❑Door(s) �,Remodel ❑ Fire Damage MCWD review 8�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 /> Phone: 952-471-0590
<br /> ❑Re-roof,other(spectfy) ❑Siding ❑Other: (specify) Fax: 952-471-0682
<br /> �Window(s) www.minnehahacreek.ora
<br /> Estimated Construction Valuation of Project(excluding land) $ ; �� D�
<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 hislher 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 which generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I th infor ion, the a lication ma not be issued.
<br /> ' ��,' ._�-�..,�_�. r •i � :?..�� �C� \ �_.
<br /> ApplicanYs Signature: �.'�"�c�� - Date: .- I .-� . �
<br /> � .
<br /> Owner's Signature: Date:
<br /> Last Updated:03/06/2013
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