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Cit of Orono � 7��� ��
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<br /> Bui!ding Permit Application for Maintenance / Replacement / Renovation
<br /> ` (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: �
<br /> g-��O PO Box 66 Permit number: �01 —DD l�S
<br /> Crystal Bay, MN 55323-0066 Date received: Z'�8'�`�
<br /> Street Address: • � Received by: �S
<br /> y� ` 2750 Kelley Parkway Plan review fee: 0 �
<br /> l,ykFSHO��,C' Orono, MN 55356� ����� d���/_�jDl (�
<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: �-7C(� �C� x �,�-j-, ���� �2'c'' '�Y���' �`� '� ���
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No
<br /> If yes, a special event permit is required with Police Department and City Council approval 60 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/APPLICANT INFORMATION:
<br /> Name: y -- _�L=1�J `3j.N J-„ �. V�rJ��f�.� ��r��F'/��J`�' .
<br /> State License# ��(>(�y ].jGil"�i Expiration Date: � ,�j /y
<br /> Lead Certification Number: fj 7-_ r.�^�,�--� _ j Expiration Date: t,,�2 2)�,5
<br /> (for work on homes that w�re constructed prior to 1978 - .
<br /> Phone: (cell) ��;,i�>;t,.�. -�,l))�j (office) �J�,' _h, L)L��/ `L�`���
<br /> Mailing Address: Z t�j � , y ;_- . �,�� �r /Y�=, ity: �,A N Ti ZIP: ���-Gyy/,>
<br /> Contact Person: j� �; '�' A licant is: on rac or / Homeowner (Circle One)
<br /> �".�,,,�s .._)AK+��/� PP�
<br /> Email and/or Fax: „�,y�=^;n;' � y��,r�r�r��('�j�'j';�r���M�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �12���:ir'�,a<v i�_ �' �11 V rt� ���.� G jY���-i J�-'�D
<br /> Phone (day):
<br /> Address: t7�-�C� �—�X �iyr�l--�-t- City: �2C�U�� ZIP: :,�C,�v��/
<br /> Email and/or Fax:
<br /> i�F:-Ma T4 1 i.- ,tl �N- _N - .
<br /> PROJECT INFORMATION: Overall projectdescription:'f�=�%/+��= ',��5 �+��^,�G�'�=�:= i�f^it� ��=�1-' �.%G��
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) 0 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 /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> �Window(s) www.minnehahacreek.or
<br /> Estimated Construction Valuation of Project(excluding land) $ `�) ODO . /5�''�0� =- r c I,���v
<br /> % ,✓Aiii .v�'yv�,, 7'c�i►z
<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 which generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this inform � is to an ally update ur records and records of other governmental agencies required by law. If
<br /> ou refuse to su I th ' form ti n, e li io a not be issued.
<br /> ApplicanYs Signature: Date: '2 �D1�`�
<br /> Owner's Signature: Date:
<br /> Last Updated: 03/06/2013
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