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City of Orono ' �, �. �d �1 �J
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> I j%�O ,'`�� Mailing Address� � Permit number: O�� 7
<br /> 1�� PO Box 66
<br /> r � � C rystal Ba y, MN 55323-0066 �-��-�3 Date receiv ed: 7- ���3
<br /> �' ; Street Address: Received by:
<br /> '` � �1 2750 Kelle Parkwa
<br /> ` r � 1 ' Y Y Plan review fee�
<br /> � 6 �%
<br /> �,,tq�C �,� ,. Orono, MN 55356
<br /> �_�s��.�--� �� �a�. �
<br /> —.- Total Fee:
<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 /> �
<br /> Job Site Address: ,� 7��L� �j����' `�:v�'� 1 I � C'�i��='
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No
<br /> /f 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/AP�LICANT INFORMATION:
<br /> Name: u�, .� � • �. ., ��',� , ��
<br /> t C
<br /> State License# , ����_3�r' Expiration Date: 31 • �
<br /> y��
<br /> Lead Certification Number: ,V��_2337�?�f Expiration Date: yl G;/ZOlS�
<br /> (for work on homes that were constructed prior to 1978 `
<br /> Phone: (cell) (�;j Z - '�- ' G`( (office) `7(;;3 - 7��'-vu 'j�-
<br /> Mailing Address: �lL y0�� �v� lll� City: c��lulc�rb�u ���qI��SZIP: S,S��I
<br /> Contact Person: S"f� �y Applicant is:�'Con r`�ac�orj/ Homeowner (Circle One)
<br /> Email and/or Fax: �'�-«j�;yr �� ,i. � `� �" ,� , `���
<br /> PROPERTY OWNER INFORMAT/IO�I: � �,/
<br /> Name: R�C�ckr�( � /-lVtYl /"lui''��� v
<br /> Phone (day): (plZ-1�0/-72 Z /'
<br /> Address: _3��U 1 1 � �d�zl�l CitY: ��^Di'1G� ZIP: � �5 ��
<br /> Email and/or Fax: y��,y�u�'�ky(�'�y �,,•l�^ •t�PS�'�a i Ic�-,r'• c�orl 1
<br /> PROJECT INFORMATION: Overall pro�ect descri tion:
<br /> Type of Project: � � Any earth movement may also require
<br /> ��;�,�,,,� �E-���,i�'-,�c 2��� ;��v��µr S ,�e�, �
<br /> ❑ Door(s) ❑ Remodel f ❑ Fire Da ge MCWD review&permits:
<br /> �Re-roof,asphalt .S<'�c�ic�5 ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> ❑ Re-roof,other(specify) ❑ Siding ❑Other: (specify) Phone: 952-471-0590
<br /> �� Si�� -'`� �� { ❑Window s Fax: 952-471-0682
<br /> ' J�'<<t'� �ar�ie ( )�, www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ 3��s i'�,��C�
<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 are
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to
<br /> 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 data.
<br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I the information,t e a lication ma not be issued.
<br /> ApplicanYs Signature: � �si.vt ` Date: ,�--3C -'/�
<br /> Owner's Signature: Date:
<br /> Last Updated:03/06/2013
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