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. A. .
<br /> �, . .
<br /> . City of Orono $��� ��� �
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<br /> Building Permit Application for Maintenance / Renovation �. .t��_xY �r�;
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number: ��/�`b�
<br /> /'4v 0,� PO Box 66
<br /> � �,� � Crystal Bay, MN 55323-0066 Date received: / Q / ,,
<br /> �� �
<br /> �a � �-� �, ' Street Address: Received by: �
<br /> �� "z'� �ti 2750 Kelley Parkway Plan reviewfee: �`
<br /> �'�kEsxo4'� Orono, MN 55356 / . ��
<br /> Total Fee: �'/ l�� �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 7`�
<br /> �;;;;
<br /> This appfication form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print) ��
<br /> GENERAL INFORMATION: �
<br /> Job Site Address: �) �c� ����� �,��^,,,., ��� �$
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Dis la Home? �
<br /> p y ❑ Yes ❑ No �
<br /> .. lf yes,a specia/event permit is required with Police Department and City Counci/approva/60 days prior to the evenf. Shuttle bus service wil/be
<br />�"' required unless applicant demonstrates sufficienf on-site parking is available. Non-permitted events will not be allowed. �r�
<br /> �;
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br />�.' Name: <�� ScYi �.��N� � � T�o,�S L(C
<br /> �i� State License# ��
<br /> ., cr63i�G"� Expiration Date: � �� 3 �
<br /> �= Lead Certification Number: Expiration Qate: ,,�.
<br /> (for work on homes that were constructed prior fo 1978 �•
<br /> Phone: �� �- (office) cell
<br /> � ���� y i i /� 3 � � , ,
<br /> k . Mailing Address: �- `� , , City: ti,se ZIP: ���,
<br />�� Contact Person: ���� � Applicant is: ontract� / Homeowner {Cirde One)
<br />> . Email and/or Fax: /-j�,`� c�,y� ��j j _
<br /> �
<br /> PROPERTY OWNER INFORMATION:
<br /> �:
<br /> Name: �f�„� �,nS�,Z �
<br /> Phone (day): ��Z ��� y�v� �� �
<br /> Address: City: ZIP: ,r�
<br /> Email and/or Fax �1 �
<br /> :�
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require *$
<br /> ❑ Door s ❑ Fire Damage MCWD review& ermits:
<br /> ( ) ❑ Remodel P
<br /> Minnehaha Creek Watershed District(MCWD) �
<br /> e-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br /> �r LJ Re-roof, cedar Dee haven, MN 55391
<br /> ❑ Restoration ❑Water Damage p :
<br /> ❑ Re-roof, other s eci Phone: 952-471-0590 '
<br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 .__;
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Overall Project Description: o� - �,
<br /> Estimated Construction Valuation of Project (excluding land) $ 2?����� ' �
<br /> °'";
<br /> . APPLICANT ACKNOWLEDGEMENT: �
<br />"" • Agrees to provide all informafion 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 appfication 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 i formation s to annually update our records and records of other governmental agencies '�`
<br />�:,; re uired b law. If vou refuse s I the ' f rmation, the a lication ma not be issued.
<br />�"� �
<br />�. ApplicanYs Signature: � . � v"�--- �/�-/�I( +`�
<br /> Date:
<br /> �.�
<br /> ,,; Last Updated: 08-09-2011
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