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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> 0 130 Box 66 Permit number. <br /> Crystal Bay, MN 58323-0M Dale received: v �� <br /> SbreetAddress. Received by; <br /> �+ 2750 Kelley Padiway Plan review flee: �-'- <br /> 1�� Orono,MN 55356 <br /> Main; 952-248 600 Fax 952 249.4618 www,ci.orvno.mn.us Total Fee: <br /> This application form must be completed in full and all required information must be subt iltied. <br /> GENERAL INFORMgT10incomplete applications will be returned. (Please print) <br /> �1; <br /> Job.Slte Address: �} <br /> WHI this be a Parade of Homes.Remodelers Showcase Home or other Display mom—e? Y No <br /> 11YOV,a soeda/eventpemtlt requfied with Pmrce Department and Cay councb approval 6o days pftrto the evanL S&A buy aendoe wff be <br /> Mu/red unless applkarn demonsbares sufWern orr-&%--parer M is evalabla NwPpbnntlted events wRl Trot be dowed. <br /> CONTRACTOR/APPLICANT INFORMA N: <br /> Name: e <br /> ftm <br /> State License* Expiration Date: <br /> Lead Certification Number. �q _ Expiration Dste: <br /> (for work on homes Matwere consHacted prlorto 1978 <br /> Phone; RSI 0- (office) <br /> • <br /> Mailing Address: (con) <br /> C = $ <br /> Contact Penson: IP: �Applicant is: Co / Ho er (cirdsoee) <br /> Email and/or Fax _hu <br /> y <br /> PROPERTY OWNER INFORMATION; <br /> Name: PKqk <br /> Phone(day): - <br /> Address: <br /> _ Email and/or Fax City P. �5 <br /> .PROJECTINFO <br /> mov <br /> Door(s) <br /> ` W .` Arty earth ement ay requ n _ <br /> s) ❑Remodel ❑Fire Damage MIND review& ermits: <br /> ❑Re-roof,asphalt ❑ itMinnehaha Creak Wateish DlWct(MCwD) <br /> ❑Re-roof,cedar ❑'tD""image 18202 Minneton Blvd <br /> ❑Restoration ❑Water Damage Deephaven,MN 5391 <br /> ❑Re-roof,other(specKj►fSiding ❑Other.(spediy) PFmc 952-4.471- 590 <br /> ❑Window(s) WM.mlnnehahhac nr <br /> Overall Pro ect Description: <br /> Estimated Constructlon Valuation of Project(exclu mg land $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • AMN to provide all information required or requested by the Building Department; <br /> • Certifies that the imbrrndon supplled is true and correct to the best of his/her knowledge. The appocar t recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so; the ff has no altemaiive <br /> but to reject it unSl it is complete; <br /> • Some or all of the infbrmation that you are asked to provide'on this application is dasslfied by Siete k A,as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be gival D the subject of the <br /> date. Confidential data is information which generally cannot be given to either the public or the sub e et of the detL Our <br /> Pu PCW and aired b law. Ifid re ofd is info tae on Is to 0 the agcatloUpdate our records and records of other g emmer>tal agendas <br /> may not be issued. <br /> Applicant's Signature: <br /> Date: <br /> Last Updated; 0&09-2011 <br />