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16513440448 From: Olson Steve
<br /> 2017-10-11 13 20 41 (GMT)
<br /> To City of Orono Page 2 of 3
<br /> ... City of Orono
<br /> ...
<br /> Building Permit Application for Maintenance I Replacement I Remodel- Residential ONLY
<br /> ," ) r.{,,,.tyll A,.?. ". 1,, .,
<br /> ii,e, windOWS, doors, siding, re-roof,etc, - No'STRUCTURAL izAr eteigeAk.,(N)
<br /> ......___......, — ...,,
<br /> //7'9,0,Aise Mailing Address:
<br /> PO E3ox 66 Permit number: ,(7,?2/7 6/36 L-) j
<br /> ___ ___.......,
<br /> k...0 Crystal Say, MN 55323-0066 g //-/7 _.j
<br /> Dote received:
<br /> ( )
<br /> Itiv.,
<br /> Street Address: --- ----- ---
<br /> ' Received by. 'pi/I/Li
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<br /> , e -• 2750 Kelley Parkway Plan review f ......
<br /> / Orono,MN 55356
<br /> 1 Total Fee: / , n7
<br /> Main: 952-249-4600 Fax 952-249-4616 www.ei.orono.rinA f
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<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:
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<br /> Job Site Address:
<br /> ''")'--S< - / . / IL/E-41 AC-/Z._._
<br /> 0-----,.
<br /> Will this be a Parade of Homes,Remodelers--- owcase Home or other Display Home? Yes i No
<br /> If yes,a special event perm!l is required with Police.Department and City Council approval 60 days prior to the event. Shuttle bus .X ervice will be
<br /> required unless applicant demonstrates•suffident on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR i APPLiCrT iNFORMATION:
<br /> Name ,}
<br /> i -
<br /> : 0..VC /tt-IIICk itCc4-ffitecTizilit._
<br /> State License# --77 - ...- ---er- '-‘.....). Expiration Date: 3'`,. i 1 7
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<br /> Lead Certification Number641 '..- ---2''.?—n
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<br /> ,-.,..?. 7_".. ...)....._c.n,_
<br /> (for work on homes that were constructed prior to 1978 — Expiration Date
<br /> ----/- r
<br /> Phone: (cell) {officepf91 .e),S9 '-.4.(-9.-:::?.. -
<br /> Mailing Address: .0 79,99V
<br /> • 1(6r'''iz '6
<br /> . 6 e 4, -'11 --....- CitSti.74,&)- -7/?fri....10.); ZIP: ..552./,,i•—:
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<br /> Contact Person: Applicant is: cci eltreetr / Homeowner (circle one)
<br /> Email and/or Fax: 'ift. /- te'7,.„.
<br /> p.t 4 - -./ it; / _ ...._
<br /> PROPERTY OWNER INFORWION: ,
<br /> Name:
<br /> •
<br /> Phone(day):
<br /> _,„,
<br /> Address: 0;--- --7-- i ..---4_ /9(....". , City: ZIP:
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<br /> Email and/or Fax:
<br /> ' _ ...._
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: T Any earth movement rnay also require
<br /> MCWD review a permits:
<br /> U Doors) 0 Remodel EJ Fire Damage
<br /> -roof,asphalt
<br /> 0 Re-roof,cedar
<br /> ro...e 0 Repair
<br /> C Restoration D Storm.Damage
<br /> 0 Water Damage Minnehaha Creek Watershed District(1VICVVD)
<br /> 15320 Minnetonka Blvd
<br /> Minnetonka,MN 65345
<br /> Phone: 962-471-0590
<br /> 0 Re-root,other(specify) ni Siding 0 Other:(specify)
<br /> Fax: 952-471-0682
<br /> D Window(s) VAVW.Tirtnehaborreek,nm
<br /> Estimated Construction Valuation of Project(excluding land) $ 1{1(00 ,
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> r----
<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 hisJher knowledge. The applicant recognizes that they are
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to
<br /> reject it until it is complete;
<br /> , .
<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 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 information Is to annually update our records and records of other governmental agencies required by law. If
<br /> you refuse to supply ttsjpfrertaitiorthdappiication may not be issued.
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<br /> 4 /7Applicant's Signature: Date. / /? __ _
<br /> Owner's Signature:e/ Date:
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<br /> Last Updated:January 2016
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