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Mar. 21. 2018 1 : 53PM No. 4465 P. 1 <br /> City of Orono <br /> Building Permit Application for Maintenance 1 Replacement 1 Remodel— giIrtiONL <br /> (i,e.windows, doors, siding, re-roof, etc,—NO STRUCTURAL EXPANSION) _ <br /> Mailing Address: � :ay: ,,.,.�, ,:•:::�� : ' <br /> (� PO Box 86 eml,fijU(neY„` <br /> 0 Crystal Bay,MN 55323-0066 Date - - . , .. <br /> "(:Rfeceiveq:cl�e4 -- _ - <br /> y <br /> .-::-.....__ <br /> - <br /> .w Street Address: <br /> -es Y 2750 Kelley Parkway psnr�v�ew <br /> 0' <br /> Orono,MN 55356 <br /> FaX www.ci.orono.mn.us <br /> Main: 952-249-4600 :.._... �- <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 /> GEJob NERAL Slte Address:ORMATION; '7 1 i n In <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? ❑Yes .0 10 <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATI• ; <br /> Name: ` - �'y b <br /> State License# )3c-=.), 3 9 Expiration Date: 3 <br /> Lead Certification Number: — f r 7.. 33' ^ ' Expiration Date: [Fr fcSe-?-0 <br /> (for work on homes that were constructedpnor tb 197 <br /> Phone: (cell) j 'c\ 8 rO V L( 7 (office) <br /> Mailing Address: /0--7.57 Fix. (' i /J> !r R1(/'d City: jj ofZIP:,sj 5 <br /> Contact Person: i -_ Cc`Applicant is: ontraetor / Homeowner (circle pne( <br /> Email and/or Fax: p) p w,1 p vi C-o- gcher s- <br /> PROPERTY OWNER INFORM TIONi ' 1 � � <br /> Name: IvG vSanl _f1°V- "U- <br /> Phone <br /> Phone(day): , _ -, ' ' 6.4. <br /> Address: U(,) City: ZIP: <br /> Email and/or Fax: <br /> 12PROJECT INFORMATION: Overall project description: 0 WS <br /> Type of Project: ` Any ea movement may also require <br /> review&permits: <br /> ❑Door(s) LIRemodel ❑Fire Damage MCW• <br /> Minneheha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt• 0 Repair 0 Storm Damage <br /> 15320 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ['Water Damage Minnetonka, <br /> ❑Re-roof,other(specify) ❑Siding Other.(specify) 952-471-0590 <br /> .s..]:1Fax: 852471-0682 <br /> indow(s) <br /> Estimated Construction alua n of Project(excluding land) $ 3 2-SI 2.- <br /> APPLICANT <br /> rAPPLICANT ACKNOWLEDGEMENT: <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 his/her 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 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 thi� atio;il: to annus ly update our records and records of other governmental gencies required by law. If <br /> you refuse to suppl fo ,z on the .-'lication may not be issued. �j <br /> Applicant's signature: milk / <br /> l D. - a C/ I , S' <br /> Owner's Signature: Date: <br /> • <br /> Last Updated:January 2016 <br />