Rug � 11 � 2012 6 � 32AM it ' s a great dav at bover bldg � No � 3280 P . 1
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<br /> � City of Orono Y�� I
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> —•-- Mailing Address. R�rmit number:'
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<br /> Og,O,�O PO Box 66 , :
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<br /> C stal Ba . MIV 55323-0066 Dete:
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<br /> ;,Received.;by; .
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<br /> 2750 Kelle Parkwa view fee. : `::;: :-; ...::.:....:::::.,;:;;..;,..:
<br /> � Orono. MN 55356 Y Rlan re
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<br /> Main: 952-24911600 Fax: 952-249�616 www.ci.orono.mn.uS Total'Fee:`.:..:"::; ; :,: ,:, .
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<br /> � This appiication form must be completed in full and all required information must be submitted
<br /> Incomplete applications will be returned„ (Plsas�print)
<br /> GENERAL INFORMA710N�
<br /> Job Site Address: ���S Gree� �rQ,�S __�,CYc r�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No
<br /> !f yns,a special event peimit is required with Pollce Depa�tment and City Council approva�60 days prior to the event. Shuttle bus se ice wil/be
<br /> required un/ess appllcant demanstrates sufFcient on-site parfcing is available. Non permitfed events will not be allowed.
<br /> CONTRACTOR/APPLICAWT lNFORMATION: F
<br /> Name: �vY,er hvv�i��V�. �t��o� �131�._�
<br /> State License# �Cppa,��g' � Expiration Date� �-j ��
<br /> Lead Certification Number• ,a. ��3��'�„ Expiration Date�
<br /> (for work on homes that wera canstructed p�or to 9978
<br /> Phone: �'c��_t.{-y���p�� (office) � q���2�,�� (cell)
<br /> Mailing Address- �c.t�us �.�W►��;},,, �� uj (_ � City, yy��- ZIP_
<br /> Contact Person: �d� /�(����� Applicant is� ontr c o / Homeowner (ClrcleOne)
<br /> Email and/or Fax� ��_ �7S- _,��jQ�
<br /> PROPERTY OWNER 1NFORMATION:
<br /> Name: �1yv� ar `��W Q�T��
<br /> Phone (day)� ��a►� �76- � o�,�{ _.__
<br /> Address: ��..tc�� St�Ee..� TYe� y.�,c,c�.ril City: p,�p ZIP: c�- ��
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: � Any earth movement may require
<br /> MCWD review 8�permits:
<br /> ❑Door(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MGWD) �
<br /> ❑Re-roof. asphaft ❑ Repair ❑ Storm Damage 18202 Minnetonka B)vd
<br /> ❑Re-roof. cedar ❑ Restoration ❑Water Damage �eephaven, MN 55391
<br /> Phone� 952�71-0590
<br /> ❑ Re-roof. other(speclfy) ❑ Siding ❑Other (specify) Fax: 952-471-0682
<br /> C]Window(s)
<br /> www.minnehahacreek,orq
<br /> Overall Project Description: ` � � �i„e1it�
<br /> Estimated Construction Valuation of Project(excluding land) S J�i �()_
<br /> APPLICAN7 ACKNOWLEDGEMENT:
<br /> • Agr�es 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 knowfedge. The applicant recognizes that they
<br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
<br /> but to reject it until it is complete;
<br /> • Some or afl of the information that you are asked to provide on this application is classified by State Iaw as either private or
<br /> confidential. Private data is infonnation which generalfy cannot be given to the public but can be given to the subject of the
<br /> data. Confldential 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. if ou refuse to I the information, the a lication ms not be issued.
<br /> Applicant's Signature� ` � Date� 1���7����
<br /> Last Updated� 08-09-2011 ,
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