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' City of Orono
<br /> Buifding Permit Appiication for Maintenance / Replacement / Remodel
<br /> (i.e. wir�dows, doors, siding, re-roof, et�. — NO STRUCTURA,L EXPANSiON)
<br /> � Mai/ing Address: � ; -7
<br /> � � PO Box 66 Pertnit number: ,L- — CJ
<br /> o �
<br /> ' Crystal Bay,MN 55323-0066 F,,�. Date received:
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<br /> StreetAddress: �„3�' Received by: I
<br /> % �� 2750 Kelle Parkwa �� �
<br /> �. ./ Y Y �" Plan review fee:
<br /> � � Qrono,MN 55356
<br /> �'�ESF1n�/
<br /> Total Fee: ' Z Z �
<br /> Main� 952-249-4500 Fax: 952-249-4616 www.ci.orono.mri.us 3(��
<br /> This application form must be compteted in full and ail required information must be submiited. �,,,,.,�.j ,Z�, 7 i,r
<br /> Incompiete applications wiil be returned. (Please print)
<br /> GENERAL lNFORMATION:
<br /> Job Site Address: ; 1� �-�./'^_, . . , 11 =- ���: ,C:/j' . _ �: <�
<br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Dispiay Home? ❑Yes No
<br /> !f yes,a special event permit is requi�Qd with Police Department and City Counci!epprova!60 days pnor to the event. Shutt/e bus service will be
<br /> required unless applicant demonstrates sufh'cient on-site parking is available. Non-permitted events will not 6e allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: s���� �_ � ; /�.
<br /> State License# ,�l �� � l �� �J_ Expiration Date: �3 �;_;�.
<br /> Lead Certification Number: Expiration Date:
<br /> (for woik on hames that were constructed prior to 9978
<br /> Phone: (cell) ��/.Z ii o.- S"-91 �- (office) �_;�_ �_,•�;--_i'i;� �/
<br /> Mailing Address: ��/ �� �, �� .S�! Sl S/� � CitY:j�:,1F�L4 V,l ZiP: s 5 3�=• ;�
<br /> Contact Person: `', ;��-',-�l;-,,< <, � � Applicant is: �Cont�ac�� ! Homeowner �c+.��e o�e)
<br /> Email and/or Fax: _�-_.� ,= ,._,� ��:,,, ....y.�r i< , , <-.�-;, _,
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: /`� L,C f�- .,,r-„�--:- c
<br /> ( Y)� � ' � — --
<br /> Phone da �,<i� �y,- �S i S -�; �
<br /> Address: �i� - �' '
<br /> — 5 < S � . -tl, ��v .c �t City:J�,. ZIP: ; :.,.i,.�-.�
<br /> Email and/or Fax: �... „ - ,- .:�_ t:; z-,.�, ;:; -,
<br /> PROJECT INFORMQTIOlV: Overall pro"ect description: �`� ;� ' - � =� x � . '``��=_ ` ��-�-�-� ',��
<br /> Type of Project: Any earth movement may also require
<br /> ❑Door(s) ❑Remodel ❑Fire Damage MCWD review 8�permits;
<br /> ❑Re-roof,asphalt ,�Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> ❑Re-roof,cedar �Restoration ❑Water Oamage Deephaven,MN 55391
<br /> ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> S/o :� -� __ ❑Window(s) www.minnehahacreelc.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ '- -
<br /> APPLICANT ACKNOWi.EDGEMENT:
<br /> • Agrees to provide a!I information required or requested by the Building Department;
<br /> • Certifies that the information supplied is true and coRect to the best of hislher knowledge. The applicant recognizes that they are
<br /> solely responsible for submitting a complete application bei�g aware that upon failure to do so,the staff has no alternative but to
<br /> reject it until it is comptete;
<br /> • Some or all of the information that you are asked to provide on this appiication is classified by State I�w 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 data.
<br /> � Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> � intended use of this infarmation is to annually upc�ate our records and records of other governmental agencies required by law. !f
<br /> ou refuse fo su I th infomiation,the a Iication ma not be issued.
<br /> AppficanYs Signature: _�7 ' �" Date: /2- //- /�^
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<br /> Owner's Signature: ��.•����� --�''-��--�-�-��----�-- Date: ' �� �
<br /> Last Updated:January 2015
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