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<br /> . . City of Orono �`��5 �
<br /> CP
<br /> Building Permit Application for Maintenance / Renovation r� ��y '�
<br /> . (windows, doors, siding, re-roof, etc.) ;
<br />�, �
<br /> Mailing Address: �p/�_ U/��9 z
<br /> �,�. PO Box 66 Permitnumber: „
<br /> x' /O O Crystal Bay, MN 55323-0066 Date received: ��� fi �
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<br /> d �` (,� � ya ��� �, � StreetAddress: �Received by: �
<br /> � ��1-
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<br /> �',�,t � t �' �ti 2750 Kelley Parkway ' Plan reviewfee: �
<br /> 9kESH�4� Orono, MN 55356 -.
<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 /> ,� Incomplete applications will be returned. (Please print) ti�
<br /> ,� GENERAL INFORMATION: ��
<br /> Job Site Address: f' �� ��x����ir� /���c r� �
<br />� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No ;:x
<br />� If yes, a specia!event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service will be ��
<br /> required unless appficant demonstrates sufficient on-site parking is available. Non-permitted events wil!not be allowed. ;�
<br /> > _:�
<br /> CONTRACTOR/APPLICnANT INFORMATION: �
<br />` Name: ,� [J e r� 5 �r� ���r � �i�w��o� �
<br />,;,; State License# � -�y p Expiration Date: 3 -- 3�-�2 :�
<br />�,; Lead Certification Number: Expiration Date: "�
<br />� (for work on homes that were consfrucied prior to 1978 �
<br /> F� Phone: � .�j'� '�I 2�%�� J j � (office) �S � — ,� � 3 '- i'i� Z (cell)
<br /> r�°�� Mailing Address: '3 Z, � p �'j�,- q ,,,,, �,,� City: S'�. C�,u, s � IP: '
<br /> L, �fZ ��5 '�z �
<br />�� Contact Person: � �� �� Applicant is: on rac o / Homeowner (Circle One)
<br /> - Email and/or Fax: L Q� /� �, nr.L, a � ca v e . c_c�d`�
<br />�,�; PROPERTY OWNER INFORMATION:
<br /> Name: ���y r n � �i G K�i T7�C e '=
<br /> �.
<br /> Phone (day): �1�Z- `�d �C��pB �
<br /> Address: Qx o,� � City: ��, 4, ZIP: ' ^,j
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review&permits: �
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) a°
<br /> ` � Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br /> t ,:,
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ��
<br /> Pho ne: 952-471-0590
<br /> �' ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �
<br /> ❑Window(s) www.minnehahacreek.orq K='.
<br /> �; Overall Project Description: ,�
<br /> Estimated Construction Valuation of Project (excluding land) $ //� D o U ;
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<br /> APPLICANT ACKNOWLEDGEMENT: �
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<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 sofely responsible for submitting a complete application being aware that upon failure to do so, the staff has 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 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 information,the a fication ma not be issued. �
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<br />�= ApplicanYs Signature: � Date: / — �G%•-;/� ,�.
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<br />`!; Last Updated: 08-09-2011
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