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<br />:� . Ci�y of Orono , � . � ��
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<br /> �. ' Building Permit Application for Maintenance / Renovation �
<br />��: (windows, doors, siding, re-roof, etc.) �
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<br />'„ Mailing Address: Permit number: —2d`/—�/// �5
<br /> t�, Og,�,�. PO Box 66 �
<br /> r ; Crystal Bay, MN 55323-0066 Date received: Z ���
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<br /> .�a. �� � ��
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<br /> , � Received by: �
<br />�`� ,� � �,-M ,� � Street Address: �;�
<br /> � t 'a,^s'"' ti a
<br />��f ,�e, �ti 2750 Kelley Parkway Plan reviewfee: ,/
<br />� , LyxESHo�� Orono, MN 55356 �ir ��
<br />�;� � Total Fee: �� /p2�, �o� �
<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 />�': fncomplete applications will be returned. (Please print) 'r�
<br />`�� GENERAL INFORMATION: �
<br />�.' Job Site Address �� � �� ���i
<br />��` Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o
<br />� If yes, a special event permit is required with Police Department and City Council approval 60 days prior to fhe event. Shuttle bus service will be
<br />'F�, required unless applicant demonstrates sufficient on-site parking is avaifable. Non-permrtfed events will not be allowed.
<br />�" �
<br />� CONTRACTOR/APPLICANT INFORMATION:
<br />� �
<br /> Name: G aiy ;�
<br />�h �G .�i��-4 � ,�i�c t`�i�ic> ,;�
<br /> State License# � �p�, �j���f./ Expiration Date: "�/� -����
<br />��N Lead Certification Number: Expiration Date: s`�
<br /> �' (for work on homes fhat were consfructed prior o 1978 a•
<br />�,,, Phone: � .���v� (office) (cell) �
<br />� Mailing Address: �—' � � � � City• � � ��� ZIP: .y S� � }��'
<br />�� Contact Person: A licant is: Contractor / Homeowner �
<br />�.� � pp (Circle One► �
<br />�� Email and/or Fax: ��
<br />�_;:
<br />�s PROPERTY OWNER INFORMATION:
<br />��' Name: �1%/�O,�iC� �O /=�J �S�/lJ
<br />�,�; Phone (day): � -- �
<br />�`; Address: �����" `���� /���- City: ��,�J,/ ZIP: �s6�� �
<br />��` Email and/or Fax ��
<br />�; �
<br />,��> PROJECT INFORMATION: ��
<br />'�� Type of Project: Any earth movement may require �
<br />� ' ❑ Do r(s) ❑ Remodel MCWD review&permits: �
<br /> + ❑ Fire Damage ��
<br />�,� Minnehaha Creek Watershed District(MCWD) �
<br /> �e-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br />�'� Deephaven, MN 55391 �
<br />�� ❑ Re-roof, cedar ❑ Restoration ❑Water Damage �
<br /> Pho ne: 952-471-0590
<br />� . ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 �b.
<br /> ` ❑Window(s www.minnehahacreek.orq �
<br /> �� �
<br />; .; Overall Project Description: ' - ;p �'
<br />�. : � ��
<br />� ; Estimated Construction Valuatio of Project (excluding land) $ � �a ,�� r
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<br />,'-: APPLICANT ACKNOWLEDGEMENT: �
<br /> �;�
<br /> � • Agrees to provide all information required or requested by the Building Department;
<br />�-: �:�
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<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they �s'�
<br />�a.' are solely responsible for submitting a complete appfication being aware that upon failure to do so, the staff has no alternative �.'
<br /> ` but to reject it until it is complete; ��
<br /> t ; �:
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<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 />+ �, #��
<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. I# ou refus u I the info mation,the a fication ma not be issued. �
<br /> � ��
<br />` � ApplicanYs Signature: �� �' /�/� Date: � ,��
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<br /> ,� Last Updated: 08-09-2011 �
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