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Apr 16,2018 01.20 PM To. 19522494616 Page 2/2 From:Go Permits LLC Fax.8604718765
<br /> . ,
<br /> City of Orono
<br /> Building Permit Application for Maintenance I Replacement I Remodel—Re$.-ideitia110141A:
<br /> (i,c.windows,doors,siding,re-roof,etc.--NO STRUCTURAL EXPANSION)
<br /> /r-it-0.i\42_,,, Moiling Addre= Permit numbe
<br /> PO Box 66 r
<br /> /iOtiji \ Crystal Bay,MN 55323-0066 Date received: 4-21--1 --1 g
<br /> ..
<br /> I .4,
<br /> StrReceived by:
<br /> eet Arddess:
<br /> 2750 Kelley Parkway Plan review fee:
<br /> Orono,MN 55356
<br /> .‘„,ktsHo• ..,-/
<br /> ---4....-..,.....--- Total Fee;-vv. /.?0,ey.,
<br /> Main. 952-249-4500 Fax. 952-249-4616 w., 'r. .,1-
<br /> ,.?!)f,3-11ft tr,
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications Will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: 1350..._Or-12170_.04&S Pr,
<br /> Will this be a Parade of Homes,Remodelers showcase Home or other Display Home? fl Yes pi.l.
<br /> .17 yes,a spor-for 0,1)11r porrse is raquiPed with PoOse IDepartmeni and City Court&popnovaf 50 days prior fo the event SI-4,M bus service wit be
<br /> feqUirea unless appiloant demonstrates sufficient an-sile parking is available. Non-bemired ever=will net be allowed.
<br /> CONTRACTOR I APPLICANT INFORMATION:
<br /> Name; irr-PrL4(-11C,
<br /> State License# 15c1t4114f12.4,5 Expiration Date: '31 ,/ d,..bot 0
<br /> Lead Certification Number: _thypzia 6,47.,..DL. Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cre10 g(DO ii0L (office) ,g4e414.g._
<br /> Mailing Address: A(45.5pazo,T--,cia j_,,i City: Ji..,.ii. ri ,GA- Z1 :3< 530
<br /> Contact Person: .Sc, 17,1-ill:ow. rirrwael ; Applicant is-. Contractor r Homeowner mink.one)
<br /> Erhart andlor Fax: - (N.e.79trirl'as..,..brq 1/ (,,'.0- __( 71i
<br /> PROPERTY OWNER INFORMATION:
<br /> Name;
<br /> Phone(day): fig.41?..7 Ili— 1.1t 1._
<br /> Address: 135D 0 MAD amje,,,,c,,Qie: City:,eirja ylo ZIP: ,53_..5.`fa
<br /> Email andlor Fax:
<br /> PROJECT INFORMATION: Overall projet.fle$Gription:?el/We CtirVek- r•C-oqa- " , iiQ ..tors t;ex,
<br /> Type of Project I Any earth movement may also require
<br /> a
<br /> 0 Door(5,) 0 Remodel 0 Fire DamMCWD review permits:age
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> 0 Re-roof,asphalt 0 Repair C]Storm Damage
<br /> 15320 Minnetonka Blvd
<br /> 1.1 Re-roof,cedar D Restoration [1 Water Damage Minnetonka,MN 55345
<br /> C]Re-roof,Oth13 Spri
<br /> er{specify) g D OthPhone:er:(specify)
<br /> Fax: 9952471-059052-471-0662
<br /> F4indow(s) %..iwiNfrzin,lrihaty.-F,Tc,ek.oru
<br /> Estbnated Construction Valuation of Project(excluding land) $ : : at)
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> - Agrees to provide at information required or requested by the Building Department
<br /> 1 • Certifies that the information supplied is true and correct to the best of histher knowledge. The applicant rocogrftes that they are
<br /> I sway responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to •
<br /> T 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 taw as either private or
<br /> confidential. Private data is in nation which generally cannot be given to the public but can be given to the subject of the data.
<br /> Confidential data is intormaton 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 lo annually update our records and records of other governmental agencies required by law. If'
<br /> _... y.9..rqu .1,9,IP_Flphf..1-..irfprgiti.p.t!fip Acati.n rt.wrIc4 issued. _
<br /> ApplicantsSignatur • - -- --.''
<br /> 4/„Z.49— Date! Villylig . ..,... ____
<br /> Owner's Signature: -- Date:
<br /> Last Updated January 2016
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