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L ity ot orono <br /> Ruilding Permit Application for Maintenance 1 Renovation <br /> f (windows, doors, sidin , re-roaf, etc.) <br /> Ma!ling Address: Pennit number. �� Z - �� <br /> ��.� PO B ox 68 <br /> Q � Crystal Say, MN 55323-0066 Date received: — Z <br /> a a. Streef Address: Recelved by: <br /> �� � •, G'�F 2750 Kelley Parkway Plan review fee� <br /> �Fc�8Ho4`0' Orono, MN 55356 <br /> �_�- Total Fee: �5�, 7 <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 informatfon must be submitted. <br /> Incomplete applicatlons will be retumecl. (P/ease print) <br /> GENERAL INFORMATION:,^ � � <br /> Job Site Address: o� �� �'� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If ys=, a spedal event pertnli(s required wlfh Police Department and Ctfy Council apprvval 60 days prlor to fhe event. Shuttle bus service wiN be <br /> required unless applicerrt demonstratea su�cient on-site parking!s ava!laD/e. Nonpennifted etrents wlll not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �G'n�Wa.� `�y Ar�trSe�N <br /> State License# �jC�?jp�S-3 Expiration Date: 3(31 <br /> Lead Certification N urnber: (`j�--r_ a�a B 3 - 1 Expiration Date: y��5 <br /> (for work on homes that were consfructed pryor to 19T8 '� <br /> Phone: (c5�— oZ(Ot�—y�.�-� (o�ce) (cell) <br /> MaifingAddress: � , ` �• •• We�. City:�,�,�V� e ZIP: � ( 3 <br /> Contact Person; Applicant is: ntract / Homeowner �c�r�i.o�.� <br /> Email and/or Fax: <br /> PR�PERTY QWNER lMFORMATION: <br /> Name: �� i pL(Lj n�n-�,11 <br /> Phone (day): a _ �$ <br /> Address: City: Z�p; ' <br /> Email andlor Fax <br /> PROJECT INFORMATION: � <br /> Type of Project: <br /> Any earth movament may requlre <br /> ❑Door(s) ❑Remodel ❑ Fire Damage MCWD revlew S pennits: <br /> Minnehaha Creek Watershed Disirict(MCWD) <br /> ❑Re-roof,asphal! ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,�edar ❑ Restoratlon ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(apecify) ❑5iding ❑Other: (speclfy) Fax: 952�71-0682 <br /> ❑Window(s) �(� y l.�,j� �,�j +�.minnehahacreek ora <br /> Overall Project Description: �� •� ; ; <br /> Estimated Construction Valuation of Projeet(excluding land) $ r <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provlde all informaGon required or requested by the Building Department; <br /> • Certifles that the information supplied is true and correct to the best of hislher knowiedge. The applicant recognizes that they <br /> are solely responsible for subrniriing a complete application being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until it is complete; <br /> � Some or all of the information that you are asked to provide on th(s appliqtion is classified by State faw as either private or <br /> confidential. Private data is infoimation which generally cannoi be given to the public but can be given to the subject of the <br /> data. Confidential data is information whidt 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 govemmental agencies <br /> re uired b law_ If ou refuse to su I the infiormation, the a lication ma not be issued, ( <br /> Aoolicant's Sianature: d�� Date: � ��' �2.- <br /> E 'd 06i9bL9TS9 3�IA�13S 1IW213d Q '8 S f� OS ��T ZTOZ 60 ��0 <br />