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<br />` � . . City of Orono ��
<br /> Building Permit Application for Maintenance / Renovation `�
<br /> �
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number. ^ �
<br /> O�\ PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: ` /p�--'
<br /> ���3`�� Received b
<br /> a � �, Sfreet Address: Y� �
<br /> � ��;,_,%� �
<br /> ��� t � �ti 2750 Kelley Parkway Plan review fee: �
<br /> tq'kESH�4� Orono, MN 55356 �
<br /> Total Fee: [� �7 �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � 1 �'� 6
<br /> This application form must be completed in full and all required information must be submitted. ;-�
<br />- Incomplete applications will be returned. (P/ease print) �
<br />� GENERAL INFORMATIO •
<br /> Job Site Address: �� �J ,/��>-�.. �;Y� �,�- �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No �a
<br /> If yes, a special event permif is required with Po(ice Department and City Counci/approval 60 days prior to the event. Shuttle bus service wil!be �
<br />� required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. "�
<br /> �
<br /> CONTRACTOR/AP LICANT INFORMATION: ��
<br />_ Name: /h�'�z' J` C�n, V ,c:- �
<br /> " State License# ,�(�� Expiration Date: ,3/ �L �
<br />� -� - ��
<br /> Lead Certification Number: _I - ��3��—1 O - DO Expiration Date: $����2�j1 S �
<br /> (for work on homes thaf were consfructed prior to 1978 �
<br /> Phone: �j - �/J—7/4 7 (office) (cell)
<br /> Mailing Address: JS� � S�f- -�1/'�✓ City: o�.zr ZIP:�'s"�Jy �
<br />�� Contact Person: ��,Y{ ���j� Applicant is: Contractor / Homeowner (Circle One)
<br /> " Email and/or Fax: �, �t� ��L�,� y l ��,�,,i -
<br />,::,;
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: 4��-1� ,r i�-1,� �'��i-r�
<br /> Phone(day): Lx1o� ^ UZ'�SJ "c��/N�r ' �;
<br /> Address 1,3 JJ � �rr., � City: r-��.b ZIP: �
<br /> Email and/or Fax �
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<br /> PROJECT INFORMATION: �
<br /> Type of Project: Any earth movement may require �
<br /> ❑ Door s �Remodel g MCWD review&permits: f�
<br /> ( ) ❑ Fire Dama e
<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 /> ❑ Re-roof,other s eci Phone: 952-471-0590 '`
<br /> ( p iy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �
<br /> ❑Window(s) www.minnehahacreek.orq `�
<br /> �-:
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<br /> Overall Project Description:�jJ�,�,r �,.- �_„� rn , �/�.�„i j�.r�-- �r d. � r �„i �
<br /> ` Estimated Construction Valuation of Project(excluding land) $ , � f�
<br /> ��:
<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 alf 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 a�d intended use of this information is to annually update our records and records of other governmental agencies �
<br />;.�� re uired b law. If ou refuse to su I the informafion,the a lication ma not be issued.
<br /> ' __... �
<br />� ���� ��
<br /> .�: ApplicanYs Signature: ��i'�`����-----_ Date: y�/� f�
<br /> f c/ �
<br /> Last Updated: 08-09-2011 �
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