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�Tc..�-�.�. S�'��f <br /> . City of Orona <br /> Building Permit Application far Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> MaJling Address: Permit number: �4� —C��� <br /> �r a.� PO BOX 6S <br /> d �, a Crystal 8ay, MN 55323-0066 Date received: —�O / <br /> .� ,� <br /> � -'•' Street Address: Received by: �Q�' V � <br /> �, �� 2750 Kelley Parkway f'lan revlew fee: <br /> �r���o�.�' Orono, MN 55356 � <br /> Main: 952-249�600 Fax: Q5,2-249�G16 Tofal Fee: 2�<.�', �'3 <br /> w�w.ci.orono.mn ��s <br /> This application form must be compl�t�d in full and ail r�quired infprmation must be submit�ed. <br /> Incomglete appfications will be returned. (Please print) <br /> GENERAL lNFORMATION: ,�� <br /> Job Site Address: �Y,.Li�1C,� �.'(-��,,,��.j'(►l�l..C1 <br /> Wil!this be a Parade of Homes, Remode{ers Showcase Home or other Display Home? Yes ❑ N� <br /> !f yes,a speclal event peimit is requlred wifh Pol/ce beperiment and Clty Counc;l approva!60 days privr In the event_ Shuttle bus service w!!I be <br /> reqilired unless appllcant demonstrates su�cient on-slte parking is available. Non-pgrmitted events wIH not bA allowed. <br /> CONTRAC70R/APPLICANT INFO�tMATfON: <br /> Name� t���4�\ �^�1 `A��trSer� <br /> State License# '�C,\'7jp9 S� �xpiration Date� ���1 <br /> Lead Certification Number: � -T� a� a g� -} Expiration Date: �{1(s <br /> (for work an homes that were consfruc(�ed prlor to 7978 � '�" <br /> Phone� (orj�� � _�(.O�' n (office) (cetl) <br /> MailirtgAddress. � a� . i�d '•G•, W�Sk GitY:'�,pStv�l � ZIP' SSl <br /> Cpntact Person� Appficant is� ntractor / Homeawner �c�rcie ona� <br /> Email and/or�ax: � <br /> P�2bP�RTY OWNER INFORMATEON: <br /> Name: _ �Y (►e�ra d�COIr'�,r��,� <br /> Phone(day): 95c� � � �3� <br /> Address: rj; �, City: ZIP: <br /> Email andlor Fax � <br /> PROJEGT IfV�ORMATiON: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) ❑ Remodel ❑ �ire Damage MCWb revlew 8 permits: <br /> ❑ Re-roof,asphalt 0 Re air Minn�haha Creek Wate►shed Distr'rct(MCWD) <br /> i p [] Storm damage 18202 Minnetonka Blvd <br /> �]Re-roof, cedar € �]Restoration ❑Water bamage �eephaven, MN 55391 <br /> 0 Re-roof,other(specf�jr) ❑Sidin Phone: 952-471-0580 <br /> 9 ❑ �ther: (specify) Fax: 952�71-Q682 <br /> �Window(s) vrww.minnehahacreek.or4 <br /> Overall Pro"ect Description: i 0� ,� �+� ; <br /> Estlmated Construction Valuation of Project excludir�g land � � �j , . �(� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • /�grees to provide all Information required or requested by the Building Department; <br /> • Certifies that the information supplfed is tnre and eorrect to the best of his/her knawledge. The applicant recognlzes that they <br /> are solefy respansible for submitting a complete application being awa�that upon failure to do so, the staff has no alternative <br /> but fo rejeci it until it is complete; <br /> • Same or all �f the information that you are asked to provide on thls application is classified by 5tate law as either private or <br /> confidential. Private data is information whfch generally cannot be given to the public but can be given to khe subject of the <br /> data. Confdential data is information which generally cartnot be given to eithQr the public or the subJeci of the data. Our <br /> purpose and intended use of this informatlon is to annually update our records and records af ather governmental agencies <br /> _ required by law. If you refuse t�supply the information,the a licatipn ma not be issued. <br /> Andlicant's Sianature� �'�`� Date: � �� <br /> � <br />