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G�c,�-e-� q—�r— �3 � , <br /> � � � City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structurat expansion. Only windows, doors, siding, re-roof, etc.) <br /> �. r�1• . Mailing Addrgss; Permit number: p�D _ �Q <br /> ��•rl�f� PO Box 66 /� <br /> Crystaf Bay,MN 5532�0066 Date received: -I�(�— � <br /> � � StrestAddress: ReceivedbY: <br /> �� � 2750 Kelley Parkway <br /> �q�3Hd��4 Orono,MN 55356 ��feV{�W�e' i <br /> T����: 3��,2.S <br /> Main: 952-249-4600 Fex: 952-2.a9-4616 www_a. Fono.mn.us <br /> This application form must be completed in full and al)required informaiion must be submitted. <br /> Incomplete apptications will be retutned. (Please print) <br /> GENEFtAL INFORMATION: . <br /> .FOb Si#e AddreSs: .�/' ���� <br /> 1M11 thls be a para,de of Homes,Remodelers Shawcase Home or vther Display Home7 Yes o <br /> lf y�ss,e specie�ev�ent permif!s requlrud with Policie depertment and Cily Councll approve160 days prlor to fhe event. Shume bus sennce wrll be <br /> �equired unless app/icant demonsfrates sulficient on-slts perfdng is avallable. Non-permitced evgnts wil/not bs allowsd, <br /> CONTRAGTOR/APPLICANT INFQRMA ION: <br /> Name: �Q./'j l5 S�'1� x.(l , <br /> State Lioense# � EXpiration Date� - <br /> l.ead Certification Number. � - � Expiration Date: �-1,� <br /> {for wvrk on hames thst were consLucied prio,r to 1978 <br /> Phone: (cell) (offce) ��o� - v�/S'- g'�' cr7 C� <br /> Mafling Address: p��f _ N �� = Z1P: � <br /> Contact Person: �( Applicant is: Contra or Nomeowner �c��a o�� <br /> Emaif and/or Fax: j�� c� <br /> PROPERTY OWN�R INFORMATION: <br /> Name: 4-�"P!"�' f t1 <br /> Phone(day): _�� _ �' <br /> Address: r �cw�tQ — City: ZIP: <br /> Email and/or Fax: <br /> PROdECT INFORMA710N: OveraEl roject deseri tion: (!�t^ 1 (�/'LWIc� <br /> Type of PrpJeCt: My eart{t rp vement may also re4utre <br /> ❑Qoor(s) d Remodel ❑ Fire Damage MCWD review�permits� <br /> �Re-roof,asphalt ❑Repair ❑Storm Bamqge Minnehaha Creek Watershed District(MCWB) <br /> ❑Re-roof,cedar 18202 Minnetonka Blvd <br /> ❑Restoratian ❑Water Damage Deephaven,MN 55394 <br /> ❑Re-roof,otlter(specify) ❑Siding [j p{ry�-(g�G{y� PhOr1e: 952-471-0590 <br /> Fax: 952-471-06$2 <br /> ❑Window(s) www.minneh$,hacreek.ora <br /> Estimated Construction Yaluation of P�oject(excEuding land) � � " <br /> Ai'PLJCANT qCKMOWLEDGEMENT: <br /> • Agrees to provide all irrformation requEl-ed or reyuested by the Buildlhg Departrnent; <br /> • CerNfies Shat the information supplied is Uue and correct to the best of his/her k„owledge. The applicant necogn¢es that they are <br /> solely nesponsible for submitting a complete application being�vVare that upon failure to do sa,the stafF has n0 altemative but to <br /> rejed it untfl it is Complete; <br /> � Some or aq of the informatlon that you are asked to provide on thls appEication is dass�ed by SFate law as either private or <br /> con$denUal- PriVa�e data is irTformation which ganerally cannat be given to the public but can be given to the subject of the da#a. <br /> Cohfidential data is information whiGh generally ca�not be given to either the publiC or the subject of the data. Our purpose and <br /> intended use of this inf a'on is annually update our recprds and records of other gwemmental agencies required by law. If I <br /> ou refuse to su I t in ,the a (+Cation tna not be issued. <br /> App[icsnYs Signature: Date: J �� i� <br /> Owner's Signature: Date� <br /> I.ast Updated:03/06/2013 <br />