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, . City of Orono
<br /> Building Permit Application for Maintenance / Rep{acement 1 Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> �O�O Mailing Address: Permit number: �� ���
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: � �
<br /> �• � � Received by:
<br /> � � Street Address: � �
<br /> tiF 1 � 2750 Kelley Parkway ��� Plan review fee:
<br /> �' Orono, MN 55356
<br /> `�KESH��� �
<br /> Total Fee: � -�j� � �
<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 appfications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: ��` �=- � � y��: ��,� ; ��,u,L�;� �,� �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,�No
<br /> If yes,a specral event permit is required wrth Police Department and City Council approval 60 days prior to the event. Shuttle bus service wi!!be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: � >��_�,� �x v �s-� �
<br /> State License# Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) ",z.� ,_�� ?, i �� �j �� (office)
<br /> Maifing Address: "�, c�,:r,n, C��;;��.�;: u��.�,` City: r',�,ti-� ZIP: �i�, �'<�� -
<br /> Contact Person: ����, (��(,y�,,� Appficant is: Contractor / Homeowne (Circle One)
<br /> Emai! and/or Fax: �„_�;�, < <,� �� -� , � �,;^
<br /> J
<br /> PROPERTY OWNER INFORMATION:
<br /> Name, '�>.�-�..t_ (:�r �;�
<br /> Phone (day): a:�: , =- �� "3 y t ��t 'a
<br /> Address: 3; Z.����:, c�'Y `,�._..�C �Z-�� City: <<% iL,�,� ZIP: �a 3`j (
<br /> Email and/or Fax: S��c� , r.�,,L„^�,,��_ � �� ��,�,�, �•,
<br /> . � c�
<br /> PROJECT INFORMATION: Overall project description: I�—v1,Z��►.,... �,�...+;��. ���-�--`- a.a-.��^ ��-'r^���-�
<br /> Type of Project: Any eart movement may also require
<br /> (� Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> ❑ Re-roof, other(specify) �Siding ��-� ❑ Other: (specify) Phone: 952-471-0590
<br /> C` Fax: 952-471-0682
<br /> $]Window(s) www.minnehahacreek.orq
<br /> Estimated Construction Vafuation of Project(excluding fand) $ `�'�' , ���>�,
<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 are
<br /> solely responsibfe for submitting a compfete application being aware that upon failure to do so, the staff has no altemative but to
<br /> 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 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 /> ou refuse to su I th informa ion,the a lication ma not be issued.
<br /> / ^
<br /> AppficanYs Signature: / �--:-- Date: � � l`1 . 1`�
<br /> Owner's Signature: ��_ �— �^�.�— Date: �� �`I . i�I
<br /> �ast Uodatec: Q3/06/2013
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