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City of Oron© ��� <br /> , Building Permit Application for Maintenance / Renovation 10(400 <br /> c (windows, doors, siding, re-roof, etc.) <br /> �= Mailing Address. Permit number: <br /> 0 0 CO Box 66 <br /> Crystal Bay, MN 55323-0066 i Date received: <br /> 0 v <br /> b y <br /> rC. s, Street Address: <br /> Received by: <br /> •S4,L 1�„ _roti 2750 Kelley Parkway Plan review fee: <br /> "1kOrono, MN 55356 <br /> 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) <br /> GENERAL INFORMATION: 4O'O �d�n L ��E ,tne.l U� <br /> Job Site Address: ` � tL/ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus serve e will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ( <br /> c----- <br /> State License# < Expiration Date: <br /> Lead Certification Number: --- Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER Iyy.W�ORMATION: <br /> Name: LSO 03 10 ( )((/U S <br /> Phone (day): ' It. . I •mr- <br /> Address: y� h. O -� 1�� City: �� ZIP: ..II <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> Door(s) ❑ Remodel ❑ Fire Damage MCWD review& permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> Re roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar E Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re roof, other(specify) Phone: 952-471-0590 <br /> ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> I <br /> Window(s) www.minnehahacreek.orq <br /> Overall Project Description: R i Ntt,V rx0Yc i N it t,-) (,L.9 G1431tZtx-0 t <br /> Estimated Construction Valuation of Project(excluding land) $ (p b(f)0� <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 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 dat Is inf rmation which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is i r ation which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended se f thi g informatio is to annually update our records and records of other governmental agencies <br /> required by law. If you ref ise t suppl the '`f fr,rmation, the application may not be issued. <br /> Applicant's Signature: Date: a ) NO Cl <br /> Last Updated: 08-09-2011 <br />