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<br /> �` City of Orono
<br /> • Building Permit Application for Maintenance / Renovation �
<br /> � (windows, doors, siding, re-roof, etc.) ``A
<br /> �:�
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<br /> Mailrng Address: `-�
<br /> Permit number:
<br /> �,0,� PO Box 66 `'
<br /> 0 ��, �
<br /> Crystal Bay, MN 55323-0066 Date received: `�
<br /> ° ;� a, Street Address: Received by: "`
<br /> �� '�'�, Gti 2750 Kelley Parkway Plan review fee: ;
<br /> L9kESKo4F' Orono, MN 55356 t
<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.
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<br /> Incomplete applications will be returned. (Please print) :�
<br /> GENERAL INFORMATION: �
<br /> Job Site Address: _ L�C�� �,L�� �rLw �,e, �
<br /> �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No
<br /> If yes,a special evenf permif is required with Police Department and City Counci/approva/60 days prior to the event. Shuttle bus service will be �
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted evenfs wil!nof be allowed. -
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<br /> CONTRACTOR/APPUC/ANT INFORMATJON: �--
<br /> �
<br />. Name: �l✓l�,� �'�t ���o� S �
<br /> �n�• �
<br /> State License# ,3 C l0 3 S S`i � Expiration Date: 3- 3/. / 3 A
<br /> Lead Certification Number: �/,¢T ��G 3�a�� Expiration Date: G , �, �` �
<br /> (for work on homes fhaf were constructed prior to 1978 ;�
<br /> Phone: (,�z -�L5 �S �� � (office) (cell) ;�
<br /> MailingAddress: ��, f-� � �r� ,��- �,/ City: ,Qo £,�� ZIP: �,y�v, ��
<br /> Contact Person: �J,,,�� �„�,,,�S�o.,S Applicant is: ractor,. Homeowner (Circle One) `�
<br /> Email and/or Fax: ,�,,,�E Q ,/�..�,,4 � X���-�o,�1 �m� �
<br /> <�
<br /> PROPERTY OWNER INFORMATION: �
<br /> Name: _ �Zf.,✓E f�,�/�} v
<br /> Phone (daY)� Gl�� 4 7 0- 13 y q e�
<br /> Address: c/�o �r/„ ,c.�G ,,�vcr„� .l�L, City: �o,/,,,� ZIP: �
<br /> s�3 CB �
<br /> Email and/or Fax `�
<br /> ,:�;
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<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 /> `� Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ,�
<br /> '� Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 .;
<br /> Phone: 952-471-0590 �
<br /> �] Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 ;
<br /> �-bA��/L- ❑Window(s) www.minnehahacreek.orq "=
<br /> �''�
<br /> Overall Project Description: _'�
<br /> Estimated Construction Valuation of Project(excluding land) $ � 3�v - -:
<br /> �� �
<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 �
<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 f�
<br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the ;f
<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 informafion 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 fication mav not be issued. j
<br /> ApplicanYs Signature: ���� _� Date: o?_ 2� -/ � �
<br /> Last Updated: 08-09-2011 �
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