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City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY
<br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) s�
<br /> �O� Mailing Address: Permit number: ' 7- OD ? /a
<br /> O PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: �' /7
<br /> 4.
<br /> ,, Street Address: Received by:
<br /> y� L� 2750 Kelley Parkway Plan review fee:
<br /> t Orono, MN 55356
<br /> AkESHO' /5 R
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<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:
<br /> Job Site Address: `6 5 ) O I C t yc &-/ 6 ./ ha /i so- 1
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes ..No
<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/APP ICANT INFORMATION: •e
<br /> Name: � ,,c' r',e — 6.a-n c
<br /> ., (t C l o�
<br /> State License# j c 63 8.205-- Expiration Date: 3-3/-4
<br /> Lead Certification Number: ,JA r- 223 50 - Expiration Date: 3 -/ 7- 20; 2—
<br /> (for
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) co 0 - 36 b - _i-R, 367 (office) 76. 3- s--e/ - //o-v
<br /> Mailing Address: 7/ )7 m�dl,s Av-, t.J_ City:Go/ !/�//t y ZIP: SS y?-/
<br /> Contact Person: .S iz...,4_,,,,,,,,„.1_,,„ Applicant is: r Contractor / Horfieowner (circle One)
<br /> Email and/or Fax: "3-05 IN r ba-r r-,z r- - 6.0r,s�6,i,c4,1,, e.?9.r,1
<br /> PROPERTY OWNER INFORMATION: .
<br /> Name: Ailly /;"//‘-‘)--e , ,-.
<br /> Phone(day): /� n
<br /> Address: Fes"6, e,/a C ris--1‘, / (.51t../ K d'. City: c7 r?)/'m O ZIP:
<br /> Email and/or Fax: ex_,.,4Q,/ D /, ! r-qa y S . 6.0 ,,,,-
<br /> v f- -P1 0 J-G s'?c.(.-c-c a,c-0 6-4 C-L LJ\n i/0L J �6'--- �L'
<br /> PROJECT INFORMATION: Overall project description: _
<br /> Type of Project: Any earth movement may also require c. ,
<br /> ❑ Door(s) 0 Remodel MCWD review&permits:
<br /> ❑ Fire Damage -,--•
<br /> Minnehaha Creek Watershed District(MCWD) e
<br /> ❑ Re-roof, asphalt Repair 0 Storm Damage 15320 Minnetonka Blvd . •
<br /> ❑ Re-roof,cedar 0 Restoration 0 Water Damage Minnetonka, MN 55345 Z
<br /> Cl Re-roof,other(specify) ,Siding 0 Other: (specify) Phone: 952-471-0590 dT.
<br /> Fax: 952-471-0682
<br /> 0 Window(s) www.minnehahacreek.orq '
<br /> Estimated Construction Valuation of Project(excluding land) $ 7/ c
<br /> APPLICANT 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 this information is to annually update our records and records of other governmental agencies required by law. If
<br /> you refuse to supply the informa ion,thea plication may not be issued.
<br /> Applicant's Signature: - - Date: 3 - 2 y- /
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2016
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