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<br /> � ' City of Orono
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<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number: � –���
<br /> �,�,�. PO Box 66 �y
<br /> 0 � 0
<br /> Crystal Bay, MN 55323-0066 Date received: 4 � �
<br /> ,� ' i �,� s, Streef Address: Received by: �
<br /> �',�,� z a"� Gti 2750 Kelley Parkway Plan review fee:
<br /> 9kESH04� Orono, MN 55356
<br /> — Total Fee: ���O,J`s
<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: �
<br /> Job Site Address:
<br /> Will this be a Parade of Homes, Remodelers Showcase Ho or other Display Home? ❑ Yes ❑ No
<br /> If yes,a special event permit is required with Police Department and City ouncil approva160 days prior to the event. Shuttle bus service will be ;�:
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACT /APPLICANT INFORMATION:
<br /> ame: ���r�d��r �9c?�Nc.
<br /> State License# � L� Ex iration Date: �.�
<br /> S3S� P� .�- 3i- �D/�- �
<br /> Lead Certification Number: Expiration Date: ;�:
<br /> - (for work on homes that were constructed prior to 1978 �'
<br /> Phone: (office) (cell 3��
<br /> � �'':�
<br /> Mailing Address: �75' � a City: ����� ZIP: $-S�c,,�7 ��
<br /> Contact Person: Applicant is: Cont ctor / Homeowner �c��ae o�e� ���
<br /> �, Email and/or Fax: �;'
<br /> PROPERTY OWNER INFORMATION:
<br /> ��
<br /> Name: ^� ,L S` ,f�i�-�
<br /> �/C C '�";"
<br /> Phone (day):
<br /> 0
<br /> Address: lv�I� /�i;�.�z��n,� .f�s��,,,�-�'s �� City: �/�D/��l� ZIP: .�5� S,C, ;
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require �>
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> �e-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd r$;
<br /> ❑ Re-roof, cedar ❑ Restoration Deephaven, MN 55391
<br /> ❑Water Damage ';�:
<br /> Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Overall Project Description: �,��.� �,�'�' E., ` j� ,��,;�u,,,._ �� yF�,.- �,�,,��^� �
<br /> Estimated Construction Valuation of Project(excluding land) $ �����:� �t�
<br /> APPLICANT ACKNOWLEDGEMENT: `��`r
<br /> ;__;
<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
<br /> are solely responsible for submitting 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 ';�t�;
<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 /> purpose and intended use of this information is to annually update our records and records of other governmental agencies sk�
<br /> re uired b law. If ou refuse to I the i or tion,the a lication ma not be issued.
<br />, �_:
<br /> k A IicanYs Si nature: y
<br /> f- < PP� 9 � Date: ����O//
<br /> j ' Last Updated: 08-09-2011
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