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V'150. 33 L <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement/ Renovation <br /> (No-structural exparlslo_n. Only windows, doors, siding, re-roof, etc.) <br /> ��*r PO AddressBox 66 Permit number. - <br /> Q Crystal Bay,MN 55323MM <br /> 4 <br /> ES140 Date received: <br /> ,� Sim Address: Received by: <br /> G% 2750 Kelley Parkway Plan review fee: <br /> Orono,MN 55356 ^ �� , 5� <br /> .I I Total Fee: <br /> Main: 952-2494600 Fax 952-249-4816 wwdv.ry.ororo.mn as <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:Job Site Address: q� � Q &.gk <br /> Road <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No <br /> K yes,a spedaf event pwn*Is requbed wllh PoOoe Depanmert and City Coundl approval 60 days prior to the event Shuttle bus v:be <br /> mqulrW unim applicant des adit amt m"ft pa►I t is avaffeWe Mort-permftted evards wN nW be aN=ed. <br /> CONTRACTOR/APCAJNIT INFO N: <br /> Name: <br /> State License# Expiration Date: Q; 3 - a6i <br /> Lead Certification Number. AT-4490,1- 1 Expiration Date: Q-II - a o 1!5 <br /> (for work on hams timet ware constructed mor to 1978 <br /> Phone: (cell) (rp(OL-14,o-Ob Q6 (office) <br /> Mailing Address: b 1 City: ic)v ZIP <br /> Contact Penson: Applicant is: / Homeowner- (chi on). <br /> Email and/or Fax p <br /> PROPERTY OWNER INFORMATION: <br /> Name: _ &iC llYlt Ct�er <br /> Phone(day): <br /> Address: 24x5 Old R adh �_ City.co(OV16 ZIP: 16!5 311 <br /> Email and/or Fax <br /> PROJECT INFORMATION: Overall prqed Q(&irvi deck goojiS 4&Z d N-e <br /> Type of Project: earth movement nay also requi <br /> ❑Door(s) JJrRemodel ❑Fire Damage MCM review&permits: <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minneionka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other.(specify) Phone: 952471-0590 <br /> Fax 952-471-W82 <br /> ❑Window(s) www.minnehahacareek.ora <br /> Estimated Comdructlon Valuation of Project(excluding land) S b <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all Information required or requested by the Building Department; <br /> • Certifies that the Informration supplied Is true and correct to the best of hWher 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 /> • 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 date is information which generally cannot be given to the Public but can be given to time subject of the data. <br /> Confidential data Is information which generally cannot be given to either time public or the subject of the date. Our purpose and <br /> Intended use of this IMormation Is to annually update our records and words of other governmental agencies required by law. If <br /> L you refuse to suoply the Infomation theapoketion may not be Issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: Date: <br /> Last Updated:Q3==13 <br />