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� City of Orono <br /> Buiiding Permit Apptication for Main#enance / I�epiacement / Renovatian <br /> (No structural expansion. Qnly windows, doors, sidir�g, re-roof, etc.} <br /> //'.�a�,�� Mai�ing Address: _ <br /> 'V PO Box 66 Permit number: <br /> +� Crystal Bay, MN 55323-QQ66 Date received: �- <br /> !t � Received b ` <br /> � , / St�eet Address: y: <br /> ��F �`` 2750 Kelley Parkway Plan review fee: <br /> �"�Kr,�}{f���� Orono, MN 55356 <br /> ~``-��`""�J Total Fee: ��/ .7� <br /> Main: 952-249-4600 Fax: 952-24�4616 +�vww.ci.arr�no.mr�.us (P � <br /> This application form must be completed in fuli and all required information must be subrnitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMA7"ION: ..�� i , <br /> Job Sits Address: � � � �c^' � � <br /> Will this be a Parade of Homes, Rsm delers Show se Mome or other Display Home1 Yes �o <br /> H yes,a specia!event permrt rs required with Police Department and City Counci!app�oval 60 days prror to the event. Shuttle bus service wi!!be <br /> required unless applfcant demonstrates sufficient on-site parking is available. Non-permitted events will not Ue allowed. <br /> GONTRACTOR/APPLICANT INFORMATION: <br /> Name: �i �S�Ya�P �'�c3�1�ni�n�� <br /> State License# —'`�'�t ` � <br /> Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes thaf were constructed prlor to 19T8 <br /> Phone: (cell) !� �� '� (office) <br /> Mailing Address: �' � � :.-jq , _ � , �Z��. �. � _., <br /> ., � City: %� �'��„ � <br /> Contact Person: Applicant is: Contractor / omeowner �cir�ie o�e> <br /> Email and/or Fax: �j , �� f <br /> PROPERTY OWNER INFORMATION: <br /> Name: c, ,'y� �'" ,l t/\ <br /> Phone(day): � � <br /> Address `��� ��� ,- ' � �- �.,:,�'tf 1/ Ci �� � �.,, � ��J�� 1 <br /> tY� ,' �: � � � ZIP: <br /> Email and/or Fax: �� � � � <br /> PROJECT lNFOR{IPIA�ION: Overall pro�ect description: ��%� '' '"� ` � �` �� (��t �, � � <br /> Type of Project: " Any earth movement may alsa require <br /> ❑Door(s) `�Remode! ❑ Fire Damage MCWD review&permits: <br /> ❑Re-roof, asphalt ���Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof, cedar ❑Restoration 18202 Minnetonka Blvd <br /> ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑Siding ❑C}ther: (specify) Phone: 952-471-0590 <br /> ❑Window{s} Fax: 952-471-0682 <br /> w�,�r�_______a__n�iinnef��tiacreek orq <br /> Estimated Gonstruction Valuation of Project(excluding land) $ r `� <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 spplicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> 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 data. <br /> Confidential data is information which generally cannot be given to either the public or the subject af the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the information, the a lication ma not be issued. <br /> Applicant's Signature: ��g,�r����('��a�� i' �1n Date: _��=� � <br /> C�wner's Signature: � „�' �+ /�/�/�,/t;•./ �1�.^� �,� <br /> -----���� � Date: ��j <br /> Last Updated:03/06l2013 <br />