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<br /> � ` ' City of Orono
<br />`�= Building Permit Application for Maintenance / Replacement / Renovation
<br /> �,�;
<br /> _ (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> �O� Mailing Address: Permit number: ?j� 7
<br /> PO Box 66 —7 �
<br /> � Crystal Bay, MN 55323-0066 Date received: /'Z��3 �
<br />� ` Street Address: Received by: �
<br /> �3t; y� �� 2750 Kelley Parkway Plan review fe �
<br /> L Orono, MN 55356 �
<br /> �� �
<br />��; `�kFSH� 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.
<br /> Incomplete applications will be returned. (Please print) �-�2'��
<br /> GENERAL INFORMATION: �
<br /> ,
<br /> Job Site Address: 1 ��7 �� ��w► �!'`�f
<br />��� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �] No
<br /> If yes, a specia/event permif is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service will be �
<br />#,' required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be aflowed. �
<br /> � �
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> � � `»�
<br /> Name: M,
<br /> . State License# • ��� Expiration Date: 31/�Z,� ! �
<br /> ` Lead Certification Number: f��-,,�p�c��_� Expiration Date: �c�� �'�t� �
<br /> (for work on homes that were constructed prior to 1978 � �`�
<br /> Phone: (cell) (office) �j� � �2 �"' �(7��' �;�
<br /> Mailing Address: � , City: le �j ZIP: 3
<br /> f ' Contact Person: yr�;�( �r Applicant is: ntra tor / Homeowner (Circle One)
<br />;. Email andbr Fax: y�,����i,,,�������i� , �j,;�
<br />"� PROPERTY OWNER INFORMA ION: ,
<br /> Name: � 6v1 � �'e �V"ITi�'�'�"S-Dh �
<br /> ��
<br />� Phone (day): '��_2 �Zv�I��� '�
<br /> Address: �-Z� �� �,r�,,,� ��� City: r,�;�,i,� ZIP: �
<br /> w Email and/or Fax: � ,_�
<br />�: �
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<br />�� PROJECT INFORMATION: Overall project description: �
<br />� / Type of Project: Any earth movement may also require �:n
<br /> ❑ Door(s) ❑ Remodel MCWD review&permits: �'
<br /> ❑ Fire Damage �
<br />' Minnehaha Creek Watershed District(MCWD) �
<br /> �Re-roof,asphalt ❑ Repair ❑ Storm Damage
<br /> 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) ;
<br /> Fax: 952-471-0682
<br />�` ❑Window(s) www.minnehahacreek.orq "��
<br /> �
<br />� ` Estimated Construction Valuation of Project(excluding land) $_ _�?D ��
<br />�M� `�
<br /> ��
<br />'�F 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 are �.�,�
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to `�
<br /> reject it until it is complete; �
<br /> . �
<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 data. �
<br />�,, Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and �Y�
<br /> ��
<br />,• intended use of this information is to annually update our records and records of other governmental agencies required by law. If �„
<br /> h�. �i
<br /> ou refuse to su I the information,the a lication ma not be issued. �;
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<br /> . ApplicanYs Signature: �-rri,✓ (r„-:,;,� Date: �/20�%/ 3 �'
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<br /> Owner's Signature: Date: �
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<br /> #-? Last Updated: 03/06/2013 �
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