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Rug � 11 � 2012 6 � 32AM it ' s a great dav at bover bldg � No � 3280 P . 1 <br /> , . <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:' <br /> ....::..::.......:.. . . .: �..,;,.-���. <br /> -_=--__� <br /> Og,O,�O PO Box 66 , : <br /> ,, ,.. <br /> ry Y �eceived:;., . � <br /> -..;-:;;. .,.,.. <br /> C stal Ba . MIV 55323-0066 Dete: <br /> ,.�.;.: .� ,. <br /> ;:::...: <br /> , ... <br /> , .,;;,::. <br /> ;,Received.;by; . <br /> a a. Strset Addross: "'""'''' <br /> � .,.:.:•.:......:..•.•...... . . ...... <br /> G _,. .,.. ,.:.. - <br /> ':':. t:',.:,:.::>:':, ' <br /> 2750 Kelle Parkwa view fee. : `::;: :-; ...::.:....:::::.,;:;;..;,..: <br /> � Orono. MN 55356 Y Rlan re <br /> �9g�,�0$� <br /> ....:: <br /> , <br /> ____, ;:•:... <br /> '- ,... , <br /> _ <br /> Main: 952-24911600 Fax: 952-249�616 www.ci.orono.mn.uS Total'Fee:`.:..:"::; ; :,: ,:, . <br /> ••.:.:•..•.:•:..: <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 , <br />