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. � C i ty of O ro n o >> �� <br /> Building Permit Appiication for IV�aintenance / Renovafion I' <br /> � ' (windows, doors, siding, re-roof, etc.) <br /> � Mailing Address: Permit number: 0�0// -b/ / <br /> /O y O PO Box 66 _ <br /> i ��y. <br /> � Crystal Bay, MN 55323-0066 Date received: /- <br /> �a ''�"� s, ' Street Address: ' Received by: <br /> k �-<,. <br /> ���n 'o„'�,_ �ti� 2750 Kelley Parkway Ptan review fee: <br /> f�y'"� Orono, MN 55356 <br /> 9 kES�/ <br /> Total Fee: � � �J-�� �v <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This appfication 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 /> Job Site Address: -3¢�� �/.�� .i �G�3�6 L� /�'f�l/• SS3S;( <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> If yes,a specia/event permit is required with Police Department and City Counci!approval 60 days prior to the event. Shuttle bus service wil/be <br /> required unless applicant demonstrates sufficient on-site parking rs available. Non-permitted events wifl not be allowed. <br /> CONTRACTOR/APP ICANT INFORMATION: <br /> Name: �.yfj�Zkl�Ap �l�(/Sj�r/Gll� 7/YC <br /> State License# �4 3�3 7S Expiration Date: 3-�`-/Z <br /> Lead Certification Number: ��-_,699Z � Expiration Date: 7/,�-/� <br /> (for work on homes thaf were constructed prior to 1978 <br /> Phone: �z-868'p963 (office) (cell) <br /> Maiiing Address: ,s'",3�3 �j ���f ����2v� City: ���j^/67PY121P: SS 3 <br /> Contact Person: � s Applicant is: ontrac or Homeowner (Circle One) <br /> Email and/or Fax: � � ����✓OGY>CA�✓Sr2�/LJZ�-�.G�7 - /- ,�6 / <br /> PROPERTY OWNER INFORMATION: <br /> Name: _/�!//N/�lYd ,��/�lS� �l�G��/ <br /> Phone (day): L''3f36-.�O/L <br /> Address: ,3,�OS / /6yc� � City: LA�✓6 L�'�(Cv� ZIP: $".�3,�;6 <br /> Email and/or Fax �jjq�/q�`o 1�p �qG.�,v� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restorafion ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other s eci Phone: 952-471-0590 <br /> ( p fy) ❑ Siding ❑ Other: (specify} Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek,orq <br /> Overall Project Description: �iI/T�/�Z ��L ��`��,��t/ r�►/��jT �G � T�! <br /> Estimated Construction Valuation of Project(excluding land) $ �QO� <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 failure to do so, the staff has no alternafive <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. Confidential 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 th' inf atio is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse su th io h a fication ma not be issued. <br /> ApplicanYs Signature: Date: �l�' �j l� <br /> Last Updated: 08-09-2011 <br />