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, <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: ��/ � —��� v <br /> ��,0,�.\ PO Box 66 <br /> O,� Crystal Bay, MN 55323-0066 Date received: /�'� �—� � <br /> i�a �� �,�� StreetAddress: Received by: d�• � ' <br /> �_,=, <br /> 'S'�, � �� 2750 Kelley Parkway Plan review fee: <br /> L9kESIiOg'/ Orono, MN 55356 <br /> �--- - � <br /> - Total Fee: .� ��3 ,9�Q <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 /> �ob site Address: 3585 Frederick Street, Orono, MN 55391 <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: Erik Olsen <br /> State �icense# BC-468842 Expiration Date: 3-31-2014 <br /> Lead Certification Number: QB 13252g Expiration Date: 2-3-2017 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 952-473-3520 (ot�ice) 952-292-3081 (ce�q <br /> Mailing Address: City: �Ia zata Z1P: 55391 <br /> Contact Person: Erik Olsen Applicant is: ontractor / Homeowner (Circle One) <br /> Emai� and�or Fax: erik(a�cshbuilder.com Fax:952-473-3521 <br /> PROPERTY OWNER INFORMATION: <br /> rvame: lohn and Sherrv Gorman <br /> Phone (day): 651-206-7815 <br /> Address: 35�5 Frederick Street city: Orono, MN z�P: 55391 <br /> Email and/or Fax s�orman37n,�mail.com <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review 8�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 /> Phone: 952-471-0590 <br /> ]�J Re-roof, other(specify) �J Siding Some ❑ Other (specify) Fax: 952-471-0682 <br /> Patch hv firPnla�� �Window(s) 2 WWW.minnehahacreek.orq <br /> Overall Project Description: Install 2 new windows and remove masonry fireplace. Minor interior wall framing per plan. <br /> Estimated Construction Valuation of Project(excluding land) $ �5&-A9 2Z, 3�5 , p$� <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 application 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 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information, the a lication ma not be issued. <br /> �� /� / <br /> ApplicanYs Signature: .-�_�-c,.�C _;'�'�— Date: /f' �_;� - �'c�i �_ <br /> Last Updated: 08-09-2011 <br />