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C�t,c�Pc� .S'-�� -/�-- <br /> City of Orono C� � �"�'�� <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: a O/o? --O 0.3�' <br /> �,�,�.� PO Box 66 Permit number: <br /> 0 :,\ Q Crystal Bay, MN 55323-0066 Date received: �'�—��-- <br /> � ' � Received by: <br /> ,� �� t�;�-:� �, SfreetAddress: <br /> �'.�,r�,� '� Gti 2750 Kelley Parkway Plan review fee: <br /> .y �g.� Orono, MN 55356 <br /> kESK� <br /> —'_�" Total Fee: a 7! • �� <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: .� o tI 1 ` <br /> Job Site Address: �Ob✓r L1'('��G �cLhs�cT Wa'' <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 servi will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: '�CF�r KCI�LP1t/ <br /> State License# � �p1�{Q Expiration Date: `�j-3I'13 <br /> Lead Certification Number: Expiration Date: b� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: �,sZ-9,�'G- Ia� (ottice) 6lZ-�`tl0- ?�79�/ (ce��) <br /> Mailing Address: 90b (M�e�s Qrl✓�- City: � ��. ZIP: �$S•( (, <br /> Contact Person: ��� (�p,�Iti,e/ Applicant is: ntrac r Homeowner (Circle One) <br /> Email and/or Fax: ��„�� !S"L� Q�k� �Ons•�d^'� <br /> PROPERTY OWNER INFORMATION: <br /> Name: � (,Ir►t,,s <br /> Phone (day): �j' _t{ 6— g q <br /> Address: +LS 6S � � p� , Way City: (��0�1b ziP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ( ) �Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Door s 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: i.�c! V � Mrr� � <br /> Estimated Construction Valuation of Project(excluding land) $ "�,�00 <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 this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refu to I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: J�' ��" �Z <br /> Last Updated: 08-09-2011 <br />