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<br /> � �'�� � Cit of Orono �`�''�'��/�/l� �fi�
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<br /> Building Permit Application for Maintenance / Renovation �;
<br /> E� (windows, doors, siding, re-roof, etc.) �,
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<br /> Mailing Address: �d�l �� �
<br /> � '�,�. PO Box 66 Permitnumber:
<br />�° Q O Crystal Bay, MN 55323-0066 Date received: � ,�s
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<br /> ���" Received by: �
<br /> a ' ���-�� s, Street Address: a'
<br /> �,�,� � �� �ti 2750 Kelley Parkway Plan review fee: � ��
<br /> RkEs�� Orono, MN 55356 -:
<br /> Total Fee: � ���,�5 l:
<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) ;:�;;
<br /> GENERAL INFORMATION: ""
<br />�� Job Site Address: y� s ,/�.��t'�.���C
<br />�:: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �'No °�
<br />� /f yes, a special event permit is required with Polrce Department and City Council approval 60 days prior to the event. Shuttle bus service wil/be ,'����,
<br />''-� required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �,'�
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<br /> CONTRACTOR/APPLICANT INFORMATION: .
<br /> � Name: ��LG S,�ic�i�G. C o..�.5�/�t v c-�"'�'DiZ! }
<br />`'� State License# � p (p 3 ��-r?t�,.�' Expiration Date: �3/^,���Z, �
<br /> i-' Lead Certification Number: Expiration Date: ��
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<br />��`' (for work on homes that were constructed prior fo 9978 '
<br /> Phone: . �
<br />;:: �'" — � �pQ (office) (cell) �
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<br /> Mailing Address: ���/c yy�v��,y4 f 5 f-- City`y1r,,;��� �iyti,�,ZIP: _-" �` '��
<br /> rv: Contact Person: ���� Applicant is: Contractor / Homeowner (Circle One� �
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<br /> Email and/or Fax: �
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<br /> PROPERTY OWNER INFORMATION:
<br /> Name: //�,�/t/ft/,�`'rf' �e' �.�a
<br /> Phone (day): �
<br /> a:F Address: � �2 �.t /�j�j'R/�' 1„/�:�•,��,: City�,�'��s�'��t`,l�: ZIP: ��5..���� �
<br /> Email and/or Fax
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<br /> PROJECT INFORMATION: �
<br /> Type of Project: Any earth movement may require �'
<br /> MCWD review&permits: 4
<br /> ❑ Door(s) ❑ Remodel . �l
<br /> ❑ Fire Damage ��
<br /> Minnehaha Creek Watershed District(MCWD) �
<br /> (�jRe-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd #<,_
<br /> ❑ Re-roof, cedar ❑ Restoration Deephaven, MN 55391 �
<br /> ❑Water Damage Phone: 952-471-0590 ���
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<br />�.: ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
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<br /> r ❑Window(s) www.minnehahacreek.orq �''
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<br /> Overall Project Description: �
<br /> Estimated Construction Valuation of Project (excluding land) $ � � (���� Q�
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<br /> k APPLICANT ACKNOWLEDGEMENT:
<br />�' Agrees to provide all information required or requested by the Building Department; �,_
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<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
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<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 faw as either private or ��`�
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<br /> confidential. Private data is information which generally cannot be given to the pubfic 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 govemmental agencies
<br /> g'�a re uired b law. If ou refuse t I the information,the a lication ma not be issued. t�'
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<br /> A IicanYs Si nature: "� "�'"�'�� .
<br /> PP 9 � 1.�..i��� +�c , ��.�i!r��'�.,x�'�— Date: °"'.d��+'y ��.o'".s;;.�= zt:
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<br /> Last Updated: 08-09-2011
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