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Page: 2 of 3 08/30/2016 07 :55 AM TO: 19522494616 FROM: Amy Grussing PHONE #952
<br /> 9350557
<br /> City of Orono
<br /> ' Building Permit Application for Maintenance I Replacement I Remodel— Residential ONLY
<br /> ' , . windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION)
<br /> Mailing Address: Permit number: i� 14 -( j
<br /> R*. ‘., 14:
<br /> N ,.,, PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: i ' _ ( I
<br /> I Street Address: Received by:2750 Kelley Parkway Plan review fee:! Orono,MN 55356
<br /> 4i s;tk.ew Cc1 r L3
<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 /> Incom 1p ete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: WV
<br /> Job Site Address: <'i
<br /> L` . ;'" ' 1.,‘,Z14--f /6-- ``r- (
<br /> Will this be a Parade of Homes, Remodelers S,owcase Home or other Display Home? 0 YesNo --
<br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus ervice will be
<br /> required unless applicant demonstrates sufficient on-site parking is available, Non-permitted events will not be allowed,
<br /> CONTRACTOR 1 APPLICANT INFORMATION: 7 ,
<br /> Name: ) tit i', j t ' if( a/ ). r J�'G) r._..:-.l`7(
<br /> State License# `,r( (,' l /,. , ` ,. Expiration Date: 3 r,r r't' i
<br /> Lead Certification Number: A% — -7 4?7 7 2. __.-. Expiration Date:t t Ito(e2,.0
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) d.,')/;, - 3/.,::, `i— 76/y (office) 6//5 1 7,: 4--)i 'C-;
<br /> Mailing Address: ( V1 _ .., r
<br /> Contact Person: - �F , �'v' C `./t,`, Applicant is? -'Contractor / Homeowner (Circle Ona)
<br /> Email and/or Fax /r -, , ;1 a
<br /> (. i (r f 1, 4. r} i, S 'r try, t. t-�/.%`i)./ y r �'E`�: ,1
<br /> PROPERTY OWNER INFORMATIO
<br /> Name: tr ! e i r/s i -z_
<br /> Phone (day): c r.i /'c
<br /> a , j ,
<br /> Address: r // r City: ` �'` yvi ZIP; ? _ �(
<br /> Email and/or Fax:
<br /> 7-1
<br /> PROJECT INFORMATION: Overall project iiescription:m ' U' I '! -v -'o-f / ?: ""a 1. c, ,L4,-•sq efiz
<br /> type of Project: Any earth movement may also requi
<br /> I ❑ Door(s) ❑Remodel 0 Fire Damage MCWD review&permits:
<br /> ji e-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 15320 Minnetonka Blvd
<br /> Re-rout.cedar
<br /> ❑Restoration ❑Water Damage Minnetonka,MN 55345
<br /> ❑ Re-roof,other(specify) ❑Siding D Other (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ fs—Gia,2'0 0°
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department; 1
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are I
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to l
<br /> reject it until it is complete: I
<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 information,the application may not be issued.
<br /> f J
<br /> Applicant's Signature: , rf ' ,r' Date: i . / / r;.7
<br /> 1 ri
<br /> Owner's Signature: v L.' Date:
<br /> Last Updated:January 2016
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