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�; �;. <br /> � � � � ��� �; <br /> . City of Orono ��� �� � f� � <br /> Building Permit Application for Maintenance / Renovati�7,/9 �� <br /> (windows, doors, siding, re-roof, etc.) �9�Y� <br /> E; <br /> Mailin Address: �- <br /> �,0,� PO Box 66 Permit number: o?o�/ — O�O lp � <br /> Crystal Bay, MN 55323-0066 Date received: 9 ^ Z - � "� <br /> 0 � � } <br /> ,a 9� ,�� �, StreetAddress: I �' Received by: S �� <br /> �',�,� a� �Gti 2750 Kelley Parkway �I�� Plan review fee: aa(�.S I '� <br /> 9kESH�g' Orono, MN 55356 a0�� _ ��dc.. � � <br /> —_� Total Fee: � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us '� <br /> ��; <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: �j�a " /L� ��� ��%� ��/L <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be �=� <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. -��' <br /> �; <br /> CONTRACTOR/APP ICANT INFORMATIO�I: �,: <br /> Name: r'1 U��1 C1 L-�� <br /> State License# �U�y6��5�� Expiration Date: ��Z � , /� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: " - � _ ' Cj� (office) (cell) � <br /> � <br /> �. <br />�� ' <br /> Mailing Address: � � pr2 � � = City: ���� ZIP: �s,�� �. <br /> Contact Person: / A licant is: Contractor / Homeowner `'� <br /> �'"J L ' PP (Circle One) �2 <br /> Email and/or Fax: T'�,�� '- � �`v`,� . La� �; <br /> .� <br /> PROPERTY OWNER INFORMATIO : <br /> Name: p�9 .Sc n z�; <br /> Phone (day): _ 7 S 3 � <br /> � ,� <br /> Address: �c�U ����- �✓�vy� �� City: � ,/���1 ZIP: ss ,3� C� '' <br /> Email and/or Fax ',,� <br /> >4� <br /> PROJECT INFORMATION: '�' <br /> �; <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 y`.; <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Sidin �= <br /> g ❑ Other: (specify) Fax: 952-471-0682 � <br /> �Window(s) www.minnehahacreek.orq ,�� <br /> Overall Project Description: ,;r �,,�„_ ` j���� � � <br /> Estimated Construction Valuat'on of Proje (e luding land) ��phQ� � � ,� <br /> 1� <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 altemative `#` <br /> but to reject it until it is complete; :-0 <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 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 �;a <br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> � <br /> ApplicanYs Signature: Date: �� p2 D�� � <br /> � <br /> Last Updated: 08-09-2011 �� <br />