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<br /> . City of Orono � � �
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<br /> . Building Permit Application for Maintenanee / Renovation ' �i,s k �
<br /> (windows, doors, siding, re-roof, etc.) �*
<br /> Mailing Address: Permit number: �
<br /> �v�,� PO Box 66 �<
<br /> Crystal Bay, MN 55323-0066 Date received: '�
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<br /> � r Received b j�
<br /> a , �{ �;� s, Street Address: y�
<br /> �� �,,;R'�, �� 2750 Kelley Parkway Plan review fee: },�
<br /> ��kESHo�'� Orono, MN 55356
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<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: k`;��
<br /> Job Site Address: /'�� ��.�,,,,� ��,�,,.�� ���i `y,��. `�':�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No
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<br /> If yes,a special event permit is required with Police Department and City Counci/approva/60 days prior to the event. Shutt/e bus service will be �
<br /> required unless applicant demonstrates sufficient on-site parking rs available. Non-permitted events will not be allowed. ��a
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<br /> CONTRACTOR/APPLICANT INFORMATION: � `.�
<br /> Name: C f�
<br /> co 1LS7� '�t_- '��
<br /> State License# �_���.y Expiration Date: � �� _� � ���
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<br /> Lead Certification Number: Expiration Date: ;�
<br /> (for work on homes that were construcfed prior fo 1978 .�
<br /> Phone: ' -� � (office) (cell) �
<br /> Mailing Address � � � �. �, City: .:--2 ZIP: y�-� v ;�y
<br /> Contact Person: `���,.����r�_ ��s ���� Applicant is: Contractor / Homeowner (Circle One) �
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<br /> Email and/or Fax: ��
<br /> .�rys
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<br /> PROPERTY OWNE INFORMATION: �y
<br /> N a m e: c'Yt � [_.,r42��1� Ld��l �'
<br /> Phone (day): g5,�-���-R�� . >`�
<br /> Address: ja� �n�� L��,k� City:��,� ZIP: �'
<br /> Email and/or Fax ,j�
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<br /> PROJECT INFORMATION: "'•�
<br /> Type of Project: Any earth movement may require :�_;
<br /> MCWD review& ermits:
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage p �-
<br /> 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 /> ❑ Re-roof, other s eci Phone: 952-471-0590 ''
<br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Overall Project Description: = f �
<br /> Estimated Construction Valuation of Project(excluding land) $ $��'" �
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<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department; �
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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 "?
<br /> are solely responsible for submitfing 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 pub(ic 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 /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued.
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<br /> ApplicanYs Signature: --_ - Date: ����� /���
<br /> Last Updated: 08-09-2011
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