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09/22/11 9:27 AM R DAvis � 61235350h0 P�ge 1
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<br /> � City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, door�, sidin , re-roof, etc.
<br /> Mailinp Add��v: permit number: dD//- ��D
<br /> O.Q,,��.0 P�Box G6
<br /> Grys[al Bay, MN s53z3-ooee Date�ceivea: ��ZZ- 1/
<br /> a ��;, n, SheetAddress: Raceiv�ed by: � S
<br /> � , � 2750 Kelley ParKway Plan review f¢3e:
<br /> ��i�aas� Orono,MN 55356 T�tal Fee: a�a?�, a 3 .,F a°%
<br /> M�in: g5�-�49-�1600 Fax: 952-2ag�616 wwvJ ci,orono.mn.us
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<br /> This appfication form must be compt�ted in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INF�RMATION: �J��
<br /> Job Site Address: .._.I.,I✓..,�.. Y�_Y�a.. �16��
<br /> Will this be a Paratle af Hcmes,Remodslers Showcase Home or other Disptay Home? ❑Yes No
<br /> 1!yes,�aperys/eMenf permit is�quired with f�olicE Uop�rimenl and G'ily Cuuru:i!xppruvr�l B�deyA prior fp fh�ervrant Shutfle bus service will be
<br /> ►epuirgd un/ess applic2nt demonstiaies suKi�qn!on-,aiie,oerl.%ng is available. Non-paanitAed events will not bo al/owed.
<br /> CONTRACTOR/APPLI NT INFORMA�ION: `
<br /> Name: ���V�� ��/�S�I''(Jc''`f1.��...
<br /> � .... ......_.. �
<br /> State l.icsnee# �'�G���Sc�..�-5�� .... . .. �x�ir�ti���ete: � �/ =�
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<br /> Lead Ceft'rficativn Number: Expiration Dale:
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<br /> (ror worK on homes rher were consw�r prlor�o�a7a
<br /> Phone: � �� - �.��7•- j'1s :5 toffice) `�S.�'-�?S - c-�.` �;'� (ce�q
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<br /> Mailing AddresS: j,a � � .. City� ZIP: .�'"�C+' �
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<br /> Contact Person: (i , _ Applicant is: Contractor omeowner �circro v,w1
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<br /> Email and/or Fax: ,L.;Z•��",�"�,�.��.g�.-._._.��'l:�v �.J.�.t��r•V'�"s' Cf�i7Sfi�'l.��.i :•�.�".?1.�:lr..�l?.'+,��......,. .
<br /> PROPER7Y OWNER INPORMATION: ��
<br /> Name: -�l�t� '� '�� ..�.�E.�r......_... ........... . ....--- ----�--�--....... ......_....
<br /> Phone(day): �i/:.�-.�tic�'•• :a'`��' . ..
<br /> AC1Clr@SS: ���� /� �Yi�'a_��',�ir1!'_�'''-: ,_..._... . .. ...........---• Ci4Y: �l�'✓�"'7(� ZIP:
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
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<br /> Typs of Project: � Any earth mweme�t may require
<br /> �or(s) ❑Remodel ❑ Fire Damege MCWD ra�iew 8 pormits:
<br /> Mi�nehaha Creek Water3hed District(MCWD)
<br /> Re-roof,asphalt �]Repair ❑Storm 4amage 18202 MiMeLonlG3 BIVd
<br /> Deephaven,MN 55391
<br /> ❑Re-roof,cedar ❑Restoration ❑Water Damagc� phonQ: 5,�52�71-05�J0
<br /> ❑Re-rooF,ether(spoclryl rl Staing f�I Other. (speciry) Fax; 852-n7�-0862
<br /> , ❑Window(s)
<br /> www.mii�n�h�heac►��k_o��
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<br /> Overall ProjeCt De�cription•
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<br /> �stimated Conat�uction Valuation of Pro'cct cxcludin land S ,_� ��..r�)�
<br /> APPLICANT ACKNOWLEDG�M�NT:
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<br /> � ���•� Agroes to prpviqe all iniolmati0tl reqUif+ed oP requested by the BuildinS�C7eparvneM:
<br /> • Ccrtific3 thot thc infprmation aupplied ia true end correct tv Gie I�eat oF his/her knowledge. 'fhe applicarrt recognizes tfiat they
<br /> are solely respon�sible far submilting a compl�te 3pplicotion boing�qr�th�t upon failurs ta do so,ths steff has no alternetivs
<br /> t�ut to re)ect�t unm�t�s oomp�eie;
<br /> • Somo or all oi the illfol'matiorl t118t you afe asked to DrovlOe on thls appllcaqon IS Gassmed by 5t3te law 8s @itY�er private or
<br /> confidential. Privat� data is inFormation which genorally cannot be given to the public but csn be given to the subjsct of tha
<br /> data. Co�fidential data is information which generelly connot be gi�ron to eithe�the public or the subject of the dats. Ou�
<br /> purpose ana mtenovo use oT t�ls Intormation Is to annually updat.� our records and records of other govemmental agencies
<br /> re uired b law., If yqu r�fuse,to s� the i�fvrtna'on a I'c 'o m e i�s,y,eQ.,„ ,,, .,„_.,..
<br /> Applicont'�Signeture: ..... ... '��' �� � Catv:
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<br /> I.dst Updateci: 08-09-2011
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