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J y <br /> Ci#y of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.} <br /> Mailing Address: Permit number: oZb/ —d� / <br /> �,�„Q,�. �,.� PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received �/ 3—/ � <br /> '; ��e ����. <br /> ,i �`� ,,��' StreetAddress� Receivedby� <br /> ';\t ���:,5, ��i 2750 Kelley Parkway <br /> Pian review fee: <br /> �� o.,l <br /> �=�`��ESHa�,��, Orono, MN 55356 <br /> Total Fee: ���'�, �p <br /> Main: g52-249-460d Fax: 962-249-4616 �1�e��v.ci�r�no r�m��s <br /> This application form must be completed in fuli and ail required information must be submitted. <br /> incomplete appiications wili be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> .lOb Site Addt'ess: 3125 Fox Street,Ornno MN 55356 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yss 0 No <br /> lf yes,a specral event permit is required rvith Police QepaRrnent and City GounciJ approval 60 days prior to the evenG Shuii(e bus service tvi!!be <br /> required unless appifcant demonstretes suKlcient an-site parking is avaitabie. Non-permitted events wiU not be allowed. <br /> GONTRACTOR!APPLICANT INFORMATIDN: <br /> N2t712: Lind•Neison ConstrucGon Inc <br /> State License# aC3aasao Expiration Date: 3t3�t13 <br /> Lead Certification Number: R-t-iasla-io-ooaaa Expiration Date: 2�2s�is <br /> (for work on homes thaf were constructed prior to 1978 <br /> Phone: st2-2a2•3oo5 (office) s�2-2s�-soos (cell) <br /> M2illfi9 AddfSSS: 3794 299th Ave NW ��t�+: Is�nti ZIP: 55040-5956 <br /> Contact Person: �ett Ne�son Applicant is: ontractor / Nomeowner (Circle One) <br /> Email and/or Fax: jnelson�iindnelson.com <br /> PROPERTY QWNER INFORMATION: <br /> N8m8: Tim&Gayle DeVriQs <br /> Phone (day}: <br /> Address: 3t25 Fox Street City: Orono ZIP: 55356 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth maveme�t may require <br /> ❑ Door(s) � Remodei ❑Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed Qiskrict(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) �v�nnu.minn�hahacreek orq <br /> Overall Project Descriptian: New Cabinets 8 FireplacE surround and Mantel.Adding a talse beam&lighting <br /> Estimated Constructian Vaivation of Project(excluding land} $ 1A,550.Q0 <br /> APPLICANT ACKNQWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information suppiied is true and correct to the best of his/her knowiedge. The applicant recognizes that fhey <br /> are solely respansible for submitting a compiete appiication being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until if is complete; <br /> • Some or all of the information that you are asked to provide on this appiication is ciassified by State law as either private or <br /> confidentiai. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidentiai data is information which generaily cannot be givan to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annuaily update our records and records of qther governmentai agencies <br /> re uired b law. If ou refuse to su f the i�farmatian,the a lication ma not be issued. <br /> Appiicant's Sig�ature: %��-- Date: sn3ii2 <br /> Last Updated: 08-09-2011 <br />