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�IE' L�I�E , �{��� ��.�� ���Rs•���.� _ <br /> '�� P„�'rL�:�^�G C,�rJ�P,' 7a OkS�;:.vsrL <br /> City of Orono . , . . . ;� 5��,�� <br /> Building Permit Application for Maintenance / Renovation � .�- � r�m�{�,�� <br /> (windows, doors, siding, re-roof, etc.) <br /> _— Mailing Address: db/a —L��S� <br /> � � PO Box 66 Permit number. <br /> � <br /> � <br /> ���� � <br /> ��0 0\\ Crystal Bay, MN 55323-0066 Date received: � ` �'�oZJ <br /> �/ �'' !1 Received b <br /> �'a ��'��'� ;:. �,� Street Address: Y� <br /> ���`,�, ��" �,��„�� �ti� 2750 Kelley Parkway Plan review f : <br /> l `��d�%` �� Orono, MN 55356 <br /> ���9kESH�S�:.; � �� V� U/ <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:� ( �j <br /> Job Site Address: ELLE /�IZI�W�'4 <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 approval 60 days prior to the event. Shuttle bus service will be <br /> requrred unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �pRD� Sr+w1E5 �dnJs`7�12N�CT�c�v <br /> State License# ,aC�"3 I �I G� 1 Expiration Date: 3—3 i - 0701 3 <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (��3 y�q_ �� � 7 (office) G 1„2 3��_37310 (cell) <br /> Mailing Address: City: ►y/lq-PlE fLR Z�P� S 3S� <br /> Contact Person: SQ f yV� C P �E2 Sc>-zJ Applicant is: on ractor Homeowner (Circle One) <br /> Email and/or Fax: �,.< < U,�.�Jv,,, _ ��r,,,�j , �o.�,� <br /> � <br /> PROPERTY OWNER INFORMATION: <br /> Name: D� , � � � G <br /> Phone (day): S� y <br /> Address r�}.yyt� �5 ��B�,i,F City: ZIP: <br /> Email and/or Fax �r � � qus�}-a� • �z�q ��m�f l. C� <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 /> I ❑ Re-roof, asphalt �Repair � ❑ Storm Damage 18202 Minnetonka Blvd <br /> i ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> I ❑ Re-roof, other(specify) ❑ Siding �Other: (specify) Fax: 952-471-0682 <br />; ❑Window(s) T1ZuCK DR�^'�W�E� ' '�o�r' `�w•minnehahacreek.orq <br />� <br /> Overall Project Description: � j3N tz� ��'s�� Rnu G N �'drf�o�Y <br /> Estimated Construction Valuation of Project(excluding land) $ (,D� OOP) "" <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 /> required b law. If ou refuse to su the information,the a lication ma not be issued. <br /> ApplicanYs Signature: . � Date: (� � ���� <br /> Last Updated: 08-09-2011 <br />