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. � � City af Orono
<br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY
<br /> �6.i?. L"vi'sii��J�'Jv, ieu�'a`�, :�f.tst a�_'s �"i.:�e'6:r�vi'e �`'�C�. 3�� .e�i u':���,�`9��"�;x� :�.�'l��`'����i�j
<br /> /;^'�O ��, Mailing Address: Permit number: ��� (�t �� - �(; �
<br /> ,% Q�- �I � PQ Box 66
<br /> � � `` Crystaf Bay, MN 55323-0066 Date received:
<br /> � �� Received by:
<br /> �� t ? Streef Address:
<br /> �
<br /> : + � � 2750 Ke{ley Parkway Plan review fee: / ur l_L. � E��-
<br /> �t �'�/ Orono,MN 55356 '`--`� � � �
<br /> ��'�"�s Fi o�tj� ls-
<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. ��y�, s��� .�
<br /> Incomplete appiications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: Z�3C> �1o���Lk- jZ,� , p�-0,,..1 0 � ���rt �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ❑ No
<br /> !f yes, a speciat event permit is required wifh Polrce Department and City Counci!approva/60 days prior to the event. Shuttle bus service wif/be
<br /> required unless applicant demonstrates su�cient on-site parking is availab/e. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APP�ICANT INFORMATION:
<br /> Name: �.{'�,�
<br /> State License# �G, (�7�3'j 2 Expirafion Date: � 3 4 2.+� g
<br /> Lead Certification Number: ����o� —( Expiration Date: 3 � $ Zo2�
<br /> (for work on homes that were constructed prio�to 1978
<br /> Phone: (cell} ���-3'.}?- 3�5� (office)
<br /> Mailing Address: �j c�3 Sp�� S�-q,rt City: 7L�,A.�p,,,� ZIP: c��y't��`
<br /> Contact Person: b�yp ,�,��,,��c� /� App6cant is: l.6�rrtfac / Homeowner (CircleOne)
<br /> Email and/or Fax: ��tij s� �J ��rt_ ,r.,�,1 , �,,n,,r,,
<br /> PROPERTY OWNER lNFORMATION:
<br /> Name: .1"la k �?��� .�
<br /> Phone (day): �-t -- 2-3 � — �ol u l�
<br /> Address: �� ,��y LL�,,,��� City: �j�j,�.!�} ZIP: �3� ,
<br /> Email andbr Fax: n�c o,q v+�G(A�can,.�7_��LGi-r► •�d""�
<br /> PROJECT INFORMATION: Overall pro�ect description: � .��ts�wl.s
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) Remodel ❑ Fire Damage MCWD review&permits:
<br /> ❑Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 15320 Minnetonka Blvd
<br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka,MN 55345
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑Other: s e�fy) Phone: 952-471-0590
<br /> t��� Fax: 952-471-0682
<br /> ❑Window(s} =��.s.�-''�"- www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Praject(excluding land) $ 2 1?��`�
<br /> APPLICANT ACKNC?WLEDGEMENT:
<br /> . Agrees to provide all information required or requested by the Building Department;
<br /> • Ce�tifies that the information supplied is true and correct to the best of hislher knowledge. The applicant 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 /> re}ect 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 of the data. Our purpose and
<br /> intended use of this information is to annually update our records and records of other govemmental agencies required by law. If
<br /> ou refuse to su I the information,the a li tion ma �ot be issued.
<br /> ApplicanYs Signature: __��� Date: __ `J�' �2 7 ���
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2016
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