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To:City of Orono Page 2 of 2 2011-08-29 19:48:11 (GMT) 18008805798 From:Brian O'geary <br /> - <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: -Permit:nuirib <br /> -g„0,7© PO Box 66 :: .. ... .: :' '.::':•::. ;...: .. <br /> 0 Crystal Bay,MN 55323-0066 <br /> a*' , StreetAddress: Parkway <br /> t lti i'ik'4�1 2750 Ooo0o Ile k ::Plan:review fee:':: ': ,:'.. <br /> Vital.;Fee- ' ..:•••.':.`; : •:, '-'e, .,'':-....:.:•:.' - <br /> Main: 952249-4600 Fax: 952-249-4616 wvvwci.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. (PI ase print) <br /> GEJob S to LA INFORMATION: f� 0�P [h r1 K nA <br /> Job Slte Address: 1 {•� <br /> Will this be a Parade of Homes, emodelers Showcase Home or other Display Home? U Yes ['No <br /> if yes,a special event permit is required With Police Department and City Count*approval 60 days prior to the event. Shuttle bus sdfidoe will be <br /> required unless applicant demonstrates sufficient on-site parking is available, Non-permftsd events will not be allowed. <br /> CONTRACTOR I Ain24.1CANT INFORMATION: <br /> Name; ( CIX (IhDiCA ( IS <br /> State License# R( Q �pyL Expiration Date: <br /> Lead Certification Number: /� J / � Expiration Date: <br /> (for work on h a O /fit rlorio 1978 <br /> Phone (office) (cell) <br /> Mailing Address: ( ( -2 Q City: rZIP:6 90 14 <br /> a u � � <br /> Contact Person: `. i. i 4, t"ti Applicant is: sr+n+=,...=►=-/ Homeowner (Ckee on.) <br /> Email and/or Fax . , j4 ;)elearchoft A..I on t ('L <br /> PROPERTY OWN - INFO- ATION: <br /> Name: ( �' r • 1 ti- <br /> Phone(day): , I- . <br /> Address: , 750 IC-4. It 4 "• If D�D City: Arora ZIP: 5 -1 : <br /> Email and/or Fax . brikrorio ten • 1 in1Af i‘ scorn <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> CIDoar(s) ❑Remodel. ❑Fire Damage MCWD review 8.permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> 0 Re-root asphalt 0 Repair . 0 Storm Damage 16202 Minnetonka Blvd <br /> 0 Re-roof,cedar 0 Restoration 0 Phone: <br /> Water Damage v95,MN 55391 <br /> Phone: 95271-0590 <br /> 0 Re-roof,other(specify) 0 Siding 0 Other:(specify) Fax: 952471-0682 <br /> EAWindow(s)..fepl orst- www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ a 07 0. av <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • A,graAs to provide all information required or.requested.by.the Building.Department; • " <br /> " <br /> • Certifies that.the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application.being aware that.upon failure to do so,the staff hes no alternative <br /> but to 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 <br /> data. .Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of thi information is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to pply the form- on,the application may not be issued. ,,..ma,�yy��// ( <br /> Applicants Signature: r� i Ly.c l I i A S Date: 'R;2'f/L'l,f <br /> . y r <br /> Lest Updated: 08-09-2011 1 <br />