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To: Page 2 of 2 2018-04-23 19.15:06(GMT) 19529556894 From. Patrick Coty
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<br /> City of Orono
<br /> Building Permit Application for Maintenance I Replacement i Remodel- Residential ONLY
<br /> (Le,windows, doors,siding, re-roof,etc.-NO STRUCTURAL EXPANSION
<br /> -------- maging Address; O : 'op i i• , /
<br /> ' Perrnit number; Nom*
<br /> *OAF\ PC Box 55
<br /> / 0\ I Crystal Bay,MN 55323-0066 ' Date received:
<br /> ioloso.,
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<br /> Street Address. i Received by:
<br /> --.-
<br /> \ '7.',, 1 , '•i ' Plan review fee
<br /> 2750 Kelley Parkway
<br /> '"\• i"..‘4C"\ ,i.`"?
<br /> Crone,MN 55366
<br /> t,
<br /> ; Total
<br /> Mein: 952-2494600 Fax 052-249-4616 r.tww.gi.orpno,mb,us l Fee: 77• j
<br /> _
<br /> ,...
<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: ... :2 ,
<br /> Job SiteAddress
<br /> Will this be a Parade of Homes,Rernodelers S4 wcase Home or other Display Home? 0 Yes 12:1116 ,.
<br /> If yes.a special event permit is required with Police Depattment and City 1,ouri0 approval tiO days poor to the event. Shirtde Pus service will Lie
<br /> required unless applicant demonstrates sufficient on-site parking is 'ails ale Non-permitted events will not be allowed.
<br /> CONTRACTOR I APPLiCANT INFORMATION
<br /> Name: '
<br /> ,...... :-,. , 'ic.,___, ". - r ,, -„, es4+1.
<br /> State License# ..._,, ,,.. ,: , .).,,_ ,_ _______ Expiration.Date.' 3/1.5,,„/,•-•,...,,r)
<br /> --(3( ig- i•#--i9
<br /> Lead CertifiCatiOn Number: itirdi F-. ii----,h,-.• 1.2 - -2.: -' - • Expiration Date:
<br /> t ., . , .:,
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (Cell) (OffiCe) ‘,
<br /> Mailing Address i(,)0 i _6 # • ) 1 _ ..).. City /41.L.4<i.0 ....e• ZIP: _:..,'.;,-:::::,3ë/3
<br /> Contact Person: ',....- ,, .-,, „.—..;.,....„, -.,._ Applicant is: -- rr / Homeowner forcieono
<br /> 1/4.+.-----....-m-''
<br /> Email end/or Fax: C.,„rm :,ft 6,)JC"C:s ly ("0,V2Z`76)e'nfo,i 4"—.1"".7
<br /> PROPERTY OWNEIFORMATIONs
<br /> Name;
<br /> Y"': "-I5 k
<br /> Phone(day): ...q...„. ..,9":7- ,;t_gyi_l_e1 .,...,,,. .J
<br /> Address
<br /> Address: „5._10:3 .....>r,t_44 s( ” ,i-,: f.. City; L/.1.,.• -1.€,P ZIP: :'-':-., .,,..--- .... -4
<br /> Email and/or Fax: __......61 n ,-K .'. ;,,/4 c. bp„-;,,,,.-. ,,,,,vri ,t,, r,_,<,...p.01
<br /> -j \Li ---- ',,
<br /> PROJECT INFORMATION: Overall project description;
<br /> ..,,
<br /> Type of Project: My earth movement may also require
<br /> ermits:
<br /> 0 Door(s) 0 Remodel 0 Fire Damage MCWD review&p
<br /> 0 Re-root asphalt 0 Repair 0 Storm Damage
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> :15320 Minnetonka Blvd r-.
<br /> . ,
<br /> 0 Re-roof,cedar 0 Restoration 0 Water Damage Minnetonka,MN 55345
<br /> rtu...0--: Phone, 952471-0590
<br /> 0 Re-roof,other(specify) Lz-olding 0 Other:(specify) ,
<br /> Fax: 952-471-0682 .
<br /> . 0 Window(s) wmv.minnehahacreek,org,
<br /> Estimated Construction Valuation of Project(excluding land) $
<br /> APPLICANT ACKNOWLEDGEMENT: :.
<br /> . Agrees to provide all information required or requested by tne Building Depanment:
<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 alternatve but to
<br /> reject,;t until it is complete;
<br /> .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 apOicabon ma not be l
<br /> issued. '...
<br /> Aplicant'sSignatue: , --..— Date:
<br /> .......•.;:
<br /> ..._
<br /> Owner /'s Signature: „' Date:
<br /> L.,15,it Updated'January 20te
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