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- City of Orono
<br /> � Building Permit Application for Maintenance / Replacement / Remodel
<br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION)
<br /> �O�O Mailing Address: Permit number: l(�l�r '-�L� _�,�
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: --- 1 S--I l-�
<br /> � ._,
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<br /> Street Address: Received by: I�--I_�
<br /> ti�, G� 2750 Kelley Parkway Plan review fee: C` ��-��� + �,: I�c'� L� ;
<br /> Orono, MN 55356
<br /> `�kESH��� •
<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., ,� v��,y '%���/',�
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: �'�2v (�qvr� C�,,rc(�e
<br /> Will this be a Parade of Homes, Remo elers Showcase Home or other Display Home? ❑ Yes ,�No
<br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be
<br /> required un/ess applicant demonstrates suffcient on-site parking is availab/e. Non Permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �' i si-.e� �sew�Q-�
<br /> State License# 3c: �-1 (ao`l'I t Expiration Date: 3 •�
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) �Z c�q � L-i Z� � (office) �5 t ��� '7 c�c, p
<br /> Mailing Address: 5' aa � �St� i„ City: ;N�,,�� �4S ZIP: ,`S�{ ((p
<br /> Contact Person: ,��� �4,a,�,��s Applicant is '� / Homeowner (CfrcleOne)
<br /> Email and/or Fax: �Lt,,,.p���,��5 '�,,�,��sl.,.� �Sa �� _ co �
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: C I�,Y' �5�-o o�.a.-r- � ��,e.'��� �-,0-�.1� 5
<br /> Phone (day): (o�Z �c{S o(1-1,S'3
<br /> Address: _ 'a-3;Zc (�t,,-�� 1i; 2�, Cr City: L.c� C.a.�.e_ ZIP: '�53,5"(�
<br /> Email and/or Fax: " ''
<br /> PROJECT INFORMATION: Overall pro'ect description: ^" ,`F� � ', � � !_C� E,'�- �-� �'��--�'��
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) emodel ❑ 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: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ � ^� ,c�t��
<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 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 of the data. Our purpose and
<br /> intended use of this information is to annuall cords and records of other governmental agencies required by law. If
<br /> ou refuse to su I the i a cation ma not b issued.
<br /> ApplicanYs Signature: -- Date: �� I 5�r (,o
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2015 ��`G/ —, �� / �� / /„
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