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t B� ' City of Orono
<br /> ing Permit Application for Maintenance / Re lacem n �
<br /> p e t/ Remodel — �;�����,;,�►
<br /> (i.e. windows, doors, siding, re-roof, etc.— NO STRUCTURAL EXPANSION)
<br /> �Q�O Marling Address: � ,�, DC.��Z
<br /> PO Box 86 Pe►mit number, � (�' '
<br /> --•fi—•-
<br /> Crystal Bay, MN 55323-0066 Date<received:
<br /> .► Street Addr�ss: Received by:
<br /> ��. �.'� 2750 Kelley Parkway
<br /> `�'�ESHO��
<br /> �' Orono, MN 55356 Plan review feec Iq-
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: �,r� , '�d-
<br /> �'
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be retumed. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: (D � 1'Lt;,�ne{oi1�A �}; ti�u�s L��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No
<br /> N yes,a special event pemrif is required with Police Department and City Council approva!SO days prror to fhe event. Shultle bus senrice will be
<br /> required unless app!/canf demonstrates sulficlent on-site parking!s availab/e. Non permitted events will not be al/owed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: t�a.'i'11o,,,,� �fa,�C�o
<br /> State License# N�p ` Expirafion Date:
<br /> Lead Certification Number: � �� Expiration Date:
<br /> (fnr work on homes that were constructed prlor to 1978
<br /> Phone: (cell) ZI�'�'`�$" Z.3�`1 (office)
<br /> Mailing Address: �n ' h � ���5 [,�� City. � L,a,l�,¢. ZIP: � (a
<br /> Contact Person: N a,�� ��� Applicant is: Contractor / eowne (Circk One)
<br /> Email and/or Fax: no,,-(-�,��,,��a„���p � ���. ��
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �a�,� v��p
<br /> Phone(day): ��� _��_ 2�c�
<br /> Address: (y0( I�bl'�nne,�or�1L�. �`,a1�1� �.o��, C�tY' ��'Dvtio Z1P� ��3 5(�
<br /> Email and/or Fax: ��� ,,������� ��� . �� h
<br /> �
<br /> PROJECT INFORMATION: Overall pro'ect description: Iq, cuf OVtX�Lt,a� �r +��Y
<br /> Type of Project: '� °"0'r
<br /> My earth movement may also require
<br /> �Door(s) ❑Remodel ❑Fire Damage MCWD review 8 permit�:
<br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof,cedar ❑Restorapon 15320 Minnetonka Blvd
<br /> ❑Water Damage Minnetonka,MN 55345
<br /> ❑ Re-roof,other(speciTy) ❑Siding ❑Other: (specify) Phone: 952-471-0590
<br /> ❑Window(s) Fax: 952-471-0682
<br /> www.minnehahacreek ora
<br /> Estimated Construction Valuation of Project(excluding land) � p,p p
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide atl information required or requested by the Building Department;
<br /> • Certifies that the informatlon 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 altemative but to
<br /> reject it until it is complete;
<br /> • Some or all of the information that you are asked to provide on this appGcation is classified by State law as either private or
<br /> confidential. Private data is informa6on which generally cannot be given to the pubGc 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 agenaes required by law. If
<br /> ou refuse to su I the information,the a lication ma not be issusd.
<br /> ApplicanYs Signature: ��yWr✓l U�r-�'.w,e Date: _��$� I�
<br /> Owner's Signature: ���� V.�� 3 J$ � j�
<br /> Date:
<br /> Last Updated:January 2016
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