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, � <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, r�-�°•�: �:c. — !VO STRUCTURAL EXPAN� <br /> �T MailingAddress: Permitnumber: ��� S -� c�j � <br /> ���VO� �'U Box 66 q <br /> Crystal Bay, MN 55323-0066 Date received: 3 �� 6 -"�S <br /> I Received by: �.-� ^ <br /> ,� y Street Address: � <br /> y � 2750 Kelley Parkway pi�„ roti,io,r,foo; 'G�i� %�Z� G�'�� <br /> `�tq �,�' Orono, MN 55356 <br /> KfS H�� �� <br /> I Total Fee: `7'� p� , I <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us J <br /> This application form must be completed in full and all required information must be submitted. �r,�S y 31iq��s <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job �ite Address: 14�u Green �Trees koad <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 Potice Department and Crty Council approval 60 days pnor to the event. Shuttle bus servrce will be <br /> required unless applicant demonstrates su�cient on-srte parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> �' Name: Thomas Bren Homes, Inc . <br /> State License# BC12 8144 Expiration Date: 3/31/16 <br /> Lead Certification Number: NAT-1018 5 5-1 Expiration Date: 2/2 9/16 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 612-7 5 9-5 610 (office) y 5 2-4 7 5-6 i � i <br /> MailingAddress: 2073 Wayzata Blvd W City: Long Lake ZIP: 55356 <br /> Contact Person: Tom Bren Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: tbren@thomasbrenhomes .com <br /> PROPERTY OWNER INFORMATION: <br /> Name: Chris & Sarah Willson <br /> Phone(day): Chri s 612-3 8 2-7 4 9 2 <br /> ;,��,��,_ �;�y: z��: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: � Any earth movement may also require I <br /> ❑ Door(s) �J Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) I <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,ced�r � Restoration ❑JVater Damage Deepnaven, Y1N 55391 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-A7�-0582 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 2 5, 0 0 0 . 0 0 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information suaplied is true and correct to the best of his/her knowledqe. 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 altemative 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 req�aired by law. If <br /> ou refuse io su i ine informafion,ihe a licaiion ma noi be issued. <br /> Applicant's Signature: Date: 3-19-15 - <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />