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City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> �' (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> �,0,�. PO Box 66
<br /> O,�\ O \ Crystaf Bay, MN 55323-0066 Date received:
<br /> '���, . i
<br /> a � "�_ �, � Street Address: Received by:
<br /> �' � '� ez�'�� ti 2750 Kelle Parkwa
<br /> �t , ��„ �, Y Y Plan review fee:
<br /> ykESH�g,'�' Orono, MN 55356
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application 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: T : �,.-,/ • �` >- 7
<br /> >>- �' _� %�"i �` ,%���' ��. .��/,'"r' /-'"i _�S iS�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,[�No
<br /> If yes, a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will nof be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: ��;,>s�" ���s.�`n�-���;c,-� � ������� l_��.
<br /> State License# � �,{�� `,� �� yr��; Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: �/,�- ��.5=� :�i•.Z (office) (cell)
<br /> Mailing Address: .�5 j� ��'�'�,i/_SU ,����„ o ��h , City: /Jp��,,, „ ZIP: �Sg,.;��
<br /> Contact Person: ���fe� � ��j�,n s: �` Applicant is: ont_ racto� / Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ���-,:ti L�:�1, 1��-, r--
<br /> Phone (day):
<br /> Address: _�i.��' `7'; c�,C��� ���/ �� City:��.�a �q.��- ZIP: 7��.5�
<br /> Email and/or Fax
<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 ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ j/'��.�� `"
<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 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 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 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 /> Applicant's Signature: ,����Ly,��,-- ��''`�`2`��:.=�_.-` Date: ���3�i7
<br /> LastUpdated: 08-09-2011
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