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r ; , , <br /> � l b � �,�i %�_�; _ �_� . � <br /> City of Orono i�. `�- � ' , ; �'�� � <br /> Building Permit Application for Maintenan�.e / Renovation <br /> (windows, doors, siding, re-roof, ,etc.) <br /> Mailing Address: Permit number: ���v3- D� / <br /> Og,D,�.O �` PO Box 66 <br /> �� <br /> Crystal Bay, MN 55323-0066 Date received: � / / <br /> � "G Received by: <br /> ,� �J��;;, �, Street Address: <br /> 's',�,t � ���� �titi 2750 Kelley Parkway Plan reviewfee: .��.53 <br /> 9kESHOg�' Orono, MN 55356 % d0�� -OD03 <br /> —= Total Fee: <br /> Main: 952-24 600 Fax: 952-249-4616 www. :orono.mn.us <br /> This applicat n form must be completed in full a all required information must be submitted. <br /> Incomplete applications wil e returned. (P/ease print) <br /> GENERAL INFORMATION. <br /> Job Site Address: ZV P <br /> Will this be a Parade of Ho s, Remodel rs Showca e Home or other Display Home? ❑ Yes No <br /> If yes, a special event permit is re uired with Police Department nd City Council approva/60 days prior to the event. Shutt/e bus service will be <br /> required unless applic t demonstrates sufficient o -site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT I ORMATION: f- 1 <br /> Name: � C� 'Jr 0..V � S W Y►1 T�. <br /> State License# xpiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were const cted rior to 1978 <br /> Phone: (a�'Z,._ 3 2, 5(p (office) �'j 2,� z g � (cell) <br /> Mailing Address: � � � City:w 7, ZIP: 55 <br /> Contact Person: ��rn e � Applicant is: Contract r / Homeowner (Circle One) <br /> Email and/or Fax: ' S • C O �D 12- � x � ',_ _ <br /> PROPERTY OWNER INFORMAT N: ',, "��r-J"��+� <br /> Name: • �l�l � -�'E3 '(�, 4'W� il- '� <br /> Phone (day): 5 2.. �- $ I 3 b C o m e� S � �(J� "� �'�-e-1i M� <br /> Address: 3 S � r <br /> 1'�' <br /> Email and/or Fax � " ���'�' " - <br /> i 3 S r� <br /> � <br /> PROJECT INFORMAT N: <br /> Type of Project J <br /> � Door(s) ❑ Remodel ❑ re Damage �� <br /> �� <br /> ❑ Re-roof, asphalt ❑ Repair ❑ St m Damage � � <br /> ❑ Re-roof, cedar ❑ Restoration ❑Wat Damage j � C, r <br /> ❑ Re-roof, other pecify) ❑ Siding ❑Other: specify) � �� <br /> � e+�-k ❑Window(s) <br /> Overall Pr ect Description: $C c, a c.he <br /> Estimate Construction Valuation of Project(excluding la d) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the B Iding Department; <br /> • Certifies that the information supplied is true and correct to the b t of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being are that upon failure 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 a lication is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be give 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 this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: /T�/ Z p i Z __ <br /> Last Upda 2d: 08-09-2011 <br />