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� � City of Orono �r,�--����, �'��) <br /> Building Permit Applicafion for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: ���l • I <br /> 0,� � PO Box 66 Permit number: r " ' � <br /> Crystal Bay, MN 55323-0066 Date received: � c:w ; I <br /> /O,v O\ , <br /> �a , <br /> I.� ' �' s, j Street Address: Received by: <br /> , �;;<��� <br /> ��,n �� �,�� 2750 Kelley Parkway Plan reviewfee <br /> t9'kESHog'� Orono, MN 55356 <br /> Total Fee: � /-� L.� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us / �v� �/ <br /> This appfication form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: r <br /> Job Site Address: ��IC� ��,�C` S T, ����ZptJ� �J 3,� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No <br /> If yes, a specia/event permit is required with Police Department and City Council approva/60 days prior to the evenf. 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 /> 1 <br /> Name: t��'ciT�1j i ��L:�i�.l� C�:2P. <br /> State License# �'�j'�1� Expiration Date: "31�L <br /> Lead Certification Number: �—�_3�3 �� ._�� _L� ��, 3 Expiration Date: <br /> (for work on homes fhaf were consfructed prior to 1978 <br /> Phone: `��Z-40( - �,� �c�, (office) �1 Z.-3 C�3 --3 ��u (cell) <br /> Mailing Address: ���j j� yv1�NN('z.TOhl� g L�'A. City: ��,f'�„$��� ZIP: �;j�� <br /> Contact Person: ��i p F��-�j Applicant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax: j�,4vi� Q �IZc�TAS ��iLQ 1N�C���`; C._0►v� <br /> PROPERTY OWNER INFORMATION: <br /> Name: /�'I1 �� �F.� ���1� <br /> Phone (day): C�l Z-��6- Z�'LZ , <br /> Address: ;��ps �jy�; � r, City: �(Lc;�J V ZIP: 3 .� � j � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) � Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other s eci Phone: 952-471-0590 <br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overall Project Description: F�n115�..( �io IS i Iwl� �;r,/ FI� jS�..�,fLj;� C..�c,J F�R efi�.1 f`� �;�+•� <br /> Estimated Construction Valuation of Project(excluding land) $ f/U Cfpp = <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 <br /> are solely responsible for submitting a complete appfication being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the infor t you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private ata is infor tion which generaliy cannot be given to the public but can be given to the subject of the <br /> data. Confidential d a is informati which generally cannot be given to either the pub(ic or the subject of the data. Our <br /> purpose and intended use of is info mation is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou rafuse t s e information,the a a not be issued. <br /> \ - <br /> ApplicanYs Signature: �` Date: I Z--I�r� � <br /> Last Updated: 08-09-2011 <br />