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OCT-28-2011 08:06 From: 6785736615 To:9522494616 Pa9e:1�1
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<br /> . � C�i y of Orono
<br /> �uilding Permit Applic�tion for Maintenance / Renovation
<br /> (windows, d ors, siding, re-roof, etc.)
<br /> �O� i MailiPO Box 66� Permit number: 'a0 � ��013�(
<br /> O 0 � Crystal Ba�, MN 55323-008B �ate received:
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<br /> I StraetAddres$' Received by:
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<br /> G� I 2�50 Kelle Parkway Plan�eview fee:
<br /> ��gHog,� ; Orono, MN 55356
<br /> � Total Fee: l��� � �j
<br /> Main; 952-248-4600 j Fe�c' 952-249-4616 www.ci.orono.mn.us
<br /> This application forml must be comple ed in full and all required information must be submitted.
<br /> Incomplete applic tions will be returned. (Please print)
<br /> GENERAL INFORMATION:� I I-
<br /> Job Site Address: p 0 � 'C
<br /> Will this be a Parade of Ho►nes, Remodelers Sh wcase Home or other Display Home? ❑Yes �No
<br /> lt yes, a apecia!event permit is requi2d with Police Depart ent and City Counci/approva160 days p�ior ta the event. Shuttle bus service will be
<br /> requi�d unless applicant demonstPates su�cle !on-site parking is available. Nan permitted events wifl not be allowed.
<br /> CONTRACTOR I APPLICANT INFORMATION�
<br /> Name: S��.e„� �„`z�r,��,..
<br /> State License# �S � Expiration Date: ��i Z
<br /> Lead Certificatinn Number: � Expiration Date:
<br /> (for work on homes that were co�structed prior to 7978
<br /> Phone: (,, �2��, �I'L o��i (office) (cell)
<br /> Mailing Address: �-L-� �, � � �,, City:g .r,�s J��,�,_, ZI P: � ,3
<br /> Contact Persan: ' Applicant is: ntr r / Homeowner (Circle One)
<br /> Email and/or Fax: �� � �i ��. �,.-- Ca�.-
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<br /> PROPERTY OWNER INFORMATION:
<br /> Name; �,<,,,� �� ��,,�kl,� ,
<br /> Phone (day�� �� z- �-t�t`G�- �9 S`� I
<br /> Address: ��p 1 �a�- �, � - � City: mr,,,�a� ZIP: S� �" 3 � �
<br /> Email and/o� Fax � � �
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<br /> PROJECT INFORMATION:
<br /> Type of Project: i i Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel ❑ �ire Damage MCWD review 8�permits:
<br /> Minn�haha Creek Watershed District(MCWD)
<br /> (�'Re-ronf,asphalt ❑ Repair [�torm Damage 182D2 Minnetonka Blvd
<br /> ❑Re-roof,cedar �estoration ❑Water Damage Deephaven, MN 55391
<br /> i Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) ❑Siding ❑Qthgr: (specify) Faac: 952-471-0682
<br /> ❑Window(s) www,minnehahacreek.orq
<br /> Overall ProJ�ct Description; ' ,
<br /> Estimated Construction Valuatioh of Project(ex�luding land) $ �,� ,_ S 3 • 9�
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<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all informetion required or requ�ested by the Building Depanment;
<br /> • Certifies that ths information supplied is true a,nd corr�ct to the best of his/her knowledge. The applicant recognizes that they
<br /> are solely responsible for submitting a complete lapplication being aware that upon failure to do so, the staff has no alternative
<br /> but to reject it until it is comple�e;
<br /> • Some or a11 of the informatio� that you are ask d to provide on this application is classified by State lew as either private or
<br /> confidential. Private data is i�formation which generally cannot be given to the public but can be given to the subject of the
<br /> data, Confidential date is information which ge�nerally cannot be given to either the public or the subject of the data. Our
<br /> purpose and intended use of ithis information is to annually upda�te our records and records of oth6r govemmental agencies
<br /> re uired b law. If ou refuse to I the infor atio the a lication ma not be issu�d,
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