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'�"� � �', a �;7�` t ,'� <br />� .. . .'r . . . ���� . _st .. k +0..� <br /> t <br />� , � City of Orono � <br />�; Building Permit Application for Maintenance / Renovation �� <br />�;; � <br /> t3 (windows, doors, siding, re-roof, etc.) �� <br /> �� <br /> MailingAddress: Permitnumber: //- �; <br /> g,0,�. PO Box 66 , <br /> ,, <br /> � �, 0 <br /> Crystal Bay, MN 55323-0066 Date received: �, <br /> �� �� <br /> _�r� Received by: � <br /> .� :;�.� s, Streef Address: <br /> �'.�c, a�i �� 2750 Kelley Parkway Plan review fee: � <br /> � �'�gESHo�`'� Orono, MN 55356 <br />�,�' � <br /> Total Fee: ��'j�,/„5 �; <br />�•- " Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ✓ 4� �� <br /> This application form must be completed in full and all required information must be submitted. � <br /> �4 <br />� Incomplete applications will be returned. (Please print) �, <br /> GENERAL INFORMATION: �� <br /> Job Site Address: � � /Z � <br />� ,' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o ,� <br /> If yes, a special event permit is required with Police Departmenf and City Counci/approval 60 days prior to the event. Shuttle bus service wilf be �r; <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will nof be allowed. � <br /> CONTRACTOR/APP I�ANT INFORMATION: � <br /> Name: pf[/a,✓iCQ w� G.✓�ies TvrC <br /> State License# yyZ 3 Expiration Date: p 3 � <br /> ' Lead Certification Number: Expiration Date: _� <br /> rb: <br /> (for work on homes that were constructed prior to 1978 � <br /> : Phone: 76 3' 2��j'�6�S'�" (office) ��3 - $-�-Z- Zoop (cell) ;� <br />�m Mailing Address: GYap ��-f� ��, City: Fr,� (R ZIP: S`�-�/3Z <br />`�j Contact Person: a�,,,� � Applicant is: �as�cu / Homeowner (CircleOne) � <br /> : Email and/or Fax: 7��_ S-�Z - 4'4�3 � <br /> w � <br /> '� PROPERTY OWNER INFORMATION: .`� <br /> Name: r� <br />�,�� �T L,►� Mer,���, <br />� :; <br /> Phone (day): �S'Z_ � � <br /> Address: G�OS- � �„� City: Qrph� ZIP: �'$�,s"� a <br />^„�,; Email and/or Fax � <br />�J � <br /> ` PROJECT INFORMATION: � <br /> � T e of Pro'ect: � <br /> YP 1 Any earth movement may require <br />'� ' MCWD review&permits: ` <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage ° <br /> Minnehaha Creek Watershed District(MCWD) � <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 �`r <br />�; �Re-roof, cedar ❑ Restoration ❑Water Damage Phone: 952-471-0590 � <br /> ! <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 � <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overall Project Description: � ` <br /> r Estimated Construction Valuation of Project (excfuding land) $ d — � <br /> �'��' <br /> H,_ � <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 ,��. <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative §;t <br /> but to reject it until it is complete; � <br /> � <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 this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the tion, the a lication ma not be issued. � <br /> �� <br /> ApplicanYs Signature: Date: �p� � �p/� ' <br /> � � <br /> Last Updated: 08-09-2011 <br /> � <br />