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May 13 14 12: 13p Victor & Kathy Harke 507-625-3343 p. 2 <br /> Crty of Orono <br /> Building Permit Application for Maintenance 1 Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> Malling Address: Permit number. O� <br /> g.��j PO Sox 66 � <br /> 0 Crystal 8ay,MN 55323-OQ66 � Date recenred: � � <br /> a Street Address: <br /> � Received by: <br /> y �` 2750 Kelfey Parkw+ay Plan review fe� <br /> �' c. Orono,MN 55356 /D <br /> �qkESHd��' Total Fee: T� 3 �� p� <br /> Main: 952-249-4600 Fax: 952-249-4616 www•ci.orono.mn.us <br /> This applicaUon form must be completed in full and all required information must be submttted. <br /> Incomplete applicatlons will be returned. (Pleese print) <br /> GENERAL INFORMATiON: <br /> Job Site Address: t`-41��7 N�r`��� S�ldv�� � Y � �YZ t1�1 YL �j,�,� ��'.tJ <br /> Will this be a Parade of Homes,Remodelers Show�ase Nome or cther Display Home? ❑Yes No <br /> If yes,a special eveni permit is required with Police t]epartment and City Councit approva160 days prior to the event. Shutfle bus service wil!be <br /> requlred unless applicant demonsMates sufffcient on-slte parkrng!s ava11ab1e. fJon-permitted evenfs wN!not be allowed. <br /> CONTRAGTOR/APPLICAN7 tWFC?RMATlON: <br /> Name: C l� ��'� <br /> state License# ��C �33�� _ Expiration Date: C�3- 3�41(,f, <br /> Lead Certification Number: N a-�- lU�i }�I - � Expiration Date: (�3 - lC.o- l lo <br /> (for work on homes that were constructed prlor to 19T8 <br /> Phone: (cell) (office} <br /> Mai{ing Address: C y p rz City: � -�p ZIP: � p <br /> Contact Person: � ' � Applicant is: ontrac / Homeowner (Circle One) <br /> EmailandlorFax: ��„cia � 'C`n�ccsrnL�.11�s 0 � '�� c'l.s�r �� <br /> pROPERTY OWNER 1NFORMATION: <br /> Name: ,, • <br /> Phone(daY)� ��1�- �l-C��4 ��_ G-- <br /> Address: i-\�-15 i�1 t,,r-t-��� S4,oY� '(�r i v�. ��tv- ��o+�o ZIP: �j..��LC� <br /> Email andlor Fax: �; <br /> ���.�f,.�.��`�.. cx,t;•n ' ,� cvn, �'.z.ntp �ur� . �z. q..t.ea�„ o+�m• ��s-z-q,�c�cm� <br /> �(. PROJECT INFORMA710N: Overall pra"ect description: �� � �?�(t2� � <br /> Type of Project• My eaKh movement may also require <br /> � MCWD revfew&permits: <br /> ❑Door(s) ❑Remodel ❑Fire Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt �Repair ❑Storm Damage 1g2Q2 Minnetonka Blvd <br /> ❑Re-roof,aedar ❑FtestoraGon ❑Water Damage Deephaven,MN 55391 <br /> Phone: 952-471-Q590 <br /> ❑Re-roo#,other(specffy) ❑Siding ❑Other:(specify} Fax: 952-�71-0682 <br /> ❑Wlndow(s) wwrw minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) $ �' - �� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide afl information required or requested by the Building Department; <br /> . Certifies that the information supplied is true and correct to the hest of hislher knowledge. The appficant recognizes that they are <br /> solely responsible for submitting a complete application being aware ihat upon failure to do so,the statf has no aiternative but to <br /> rejsct it until it is complete; <br /> + Some or all of the infarmation that you are asksd to provide on this applicadon is classified by State law as eiiher private or <br /> con5dential. Private data is information which generally cannot be given to the public but can be gtven to the subject of the data, <br /> Confidential data is information which genera4ly cannot be given to either#he public or the subject of the.data. Our purpose and <br /> intended use of this' rmation is to annually update our records and records af other govemmental agencies required by law. lf <br /> ou refuse to su I tho formation,the a lication ma not be issued. �'' <br /> Applicant`s Signature: 1� �} Date: �` 1�� �`k' ' <br /> Owner's Signature: Date: <br /> Last Updated:03l06l2013 <br />