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City of Orono
<br /> �• Building Permit Application for Maintenance / Renovation
<br /> � (windows, doors, siding, re-roof, etc.)
<br /> �-- Mailing Address: Permit number:
<br /> /�,�,�. PO Box 66
<br /> ,i O �;, O
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> i"'fi r� Received by:
<br /> 'a s, Streef Address:
<br /> ' � .:_''_� r
<br /> �'.�c, ' �ti 2750 Kelley Parkway Plan review fee:
<br /> t9'kESH�4� Orono, MN 55356
<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: l
<br /> Job Site Address: f��.% �j f,��; j�:�� s �<� , U�ti�,�v
<br /> Will this be a Parade of Homes, Remodelers S owcase Home or other Display Home? ❑ Yes ❑ No
<br /> If yes, a special event permit is required wifh Pofice Department and City Counci!approva/60 days prior to the event. Shuftle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will nof be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �/�S�o,+ �'�.� `��,�.�c�(�..,,
<br /> State License# ���,�9�� � � 4 Expiration Date: 3 -- .-5 i -- i Z
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were consfructed prior to 1978
<br /> Phone: ��;_, , y�� -- k�«,� (office) (cell)
<br /> Mailing Address: � � 7 t -- ? � � Cit /�%� ZIP: ��3� "'
<br /> �! s �,_ >� �:� •��� /J � ,� .� l
<br /> _,._ , ,_, . �, ,
<br /> Contact Person: T,,,, �, , ��Q �s`,- Applicant is ��tra tor_��' Homeowner (CircleOne) "
<br /> _.____
<br /> Email and/or Fax: �, �Z _ ��� �, -- � .1�, �
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ��,cs�c�<��t
<br /> Phone (day): 7�� - y 7� - �?c;U
<br /> Address: 1���, /-, ��_c � 7(_�Q� ��;� City: J.,,!�r'?J ZIP:
<br /> Email and/or Fax
<br /> s
<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 /> �e-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Overall Project Description: �,�� , � ' ry ; �
<br /> �- � �l �LF la�-� r/,< ,t -���:��Lt�� ��-� ,; , �/-�
<br /> Estimated Construction Valuation of Project (excluding land) $ � y ���,
<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 fai�ure 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. Confidenfial 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. ff ou refuse to su I the inf rr�ation, the a lication ma not be issued.
<br /> /� , -
<br /> AppficanYs Signature: j��"�ti. �� �,,y` Date: �
<br /> �
<br /> Last Updated: 08-09-2011
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