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<br /> . � _3-1y �
<br /> . Ci�y of Orono �
<br /> Building Permit Applicafion for Maintenance / Renova ion g�
<br /> � �
<br /> (windows, doors, siding, re-roof, etc.) �_�
<br /> MailingAddress: Permitnumber. ���`���� I
<br /> �v 0,� PO Box 66 �
<br /> /0 � 0 Crystal Bay, MN 55323-0066 Date received: � 3 �02> ,;
<br /> I v
<br /> a a ���� �, Sfreet Address: Received by: ;
<br /> �'� ,�'�'�,���titi 2750 Kelley Parkway Plan review fee: ��
<br /> L�'kESH�� Orono, MN 55356 ,/
<br /> Total Fee: �� /7 . �.�o
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> �;;
<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: r��s 1/�Kk �,�-rV'� ����,� � �
<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 with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will nof be allowed.
<br /> A�'i,' CONTRACTOR/APPLICANT INFORMATION:
<br />� Name: � � ��� , - L �L �
<br /> State License# �" � �� Expiration Date: � 3/ /.S
<br /> Lead Certification Number: �{� �����3-� Expiration Date: � ��4,� �(�; �
<br /> (for work on homes that were constructed prior to 1978 ��;
<br /> Phone: ���Z -3�j`%� �(;�5� (office) (cell) �
<br /> Mailing Address: �3 �S ��,����Q� 'a��� City: C�,�S y� ZIP: ,� �
<br /> Contact Person: ��,�� �o(�,��,,� � Appficant is: Contractor / Homeowner (Circle One) �
<br /> Email and/or Fax: (���bo (��,,,«,,�n � Q�j�L . [��,,� �
<br /> � ,,
<br /> "t.�;
<br /> PROPERTY OWNEF�INFORMATION: �
<br /> Name: ��.�,., ��nr.,e z ��
<br /> Phone (day): /�t�L,/_ (�(v S l ��
<br /> Address: l /� ��.��G ��=v� City: V+Z c�1 c� ZIP: S.S �S � �
<br /> Email and/or Fax ;
<br /> PROJECT INFORMATION:
<br /> �::
<br /> Type of Project: Any earth movement may require
<br /> , ❑ Door(s) � Remodel ❑ Fire Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD) `:
<br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br /> fi.
<br /> ❑Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 '�
<br /> ❑ Re-roof, other s eci Phone: 952-471-0590
<br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq "��
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ s � Cj(j� '�
<br /> ;�tl:'
<br /> APPLICANT ACKNOWLEDGEMENT: ��'
<br /> • Agrees to provide all informafion 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 submitfing a complete appfication 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 lication ma not be issued.
<br /> _ ____...� .
<br /> ApplicanYs Signature: ' � � ' ` - Date: / .j ZU� Z- �
<br /> Last Updated: 08-09-2011
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