Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
�ar-12-2012 10:15am From-CITY OF ORONO +9522494616 T-4T5 P.002/002 F-255 <br /> �� <br /> City of Orono <br /> Building Permit Application for Infiernal Work � <br /> (windows, doors, s�ding, re�roof, etc_) <br /> MailingAddress: Permit number. �� — � <br /> Q PO Box GB <br /> g � Crystal Bay,MN 66323-0D66 Date recaived: <br /> 0�. 4 <br /> Sp eet Addl6ss: a�ivAd by: <br /> . �„ <br /> �� otiF 2750 Kelley ParkHrdy Plan revlewf�_ <br /> � � orono,MN 56358 <br /> T��F�: /o�,/U <br /> Malr1: 952-249-4600 F�c 852-249-46'16 wunti►.ci.orono.mn.us <br /> This app{ication form must be completed in tull and all required infnrmabo�must be submitted, . <br /> . Incomp�ete�applications will be returned, (P/eese print) <br /> G�NERAI.INFORMATIOy:y� �!r �On ,�a ,�,� Rd ` � e � �L� D�n I��� <br /> Job Site Address: �+ �l <br /> .�I(this.���Par.ade af hlomes, Remodelers Showcase Hom�or other Display Home? Yes Na <br /> • Il yes,a speoial sven!p•'r�nlr ia nquved�virh f�ol�c�•Depatinent:and C�y Co�ncii approv�.BO deys pr'ror fo;fhe avenG ShuUle btis servlcs wjH 6e <br /> reqv"aed uMesa applicant demonstrafe�suMlGent on-sIre�rkJng/s avallable. Non-pern�id9d Oven�s Wi/I not be allow�d. <br /> CON7RACTQR I APPUCANT INFORMATION: • <br /> ste eeucense# Pe�la Northland �S? •� e <br /> Phone: 15�00 25thAveN. Ste 100 (celll <br /> Mailing Address: . Pl�tnauth,MrT SS447 . Z�P� <br /> Contact Person: � � Lic#BC64509U P}�.�63/745-1400 �omeowner ��o�.� <br /> Email and/or Fax; . <br /> _._. . .... . . <br /> PROPER7Y OWNER INFOR 71qNt' <br /> Name: . , . A�F�1 J� �` .. .. . . . ... <br /> Phone(day): S� � � a'� <br /> Address: 6 Y o / e Cit : d/'O I1 O ZIP: 5+S 3 'p/ <br /> �mall and/or Fax <br /> PROJECT INFORMATION: <br /> Typa of Project: _ Any earth movement may requi� <br /> , � MGYVD raview 8 permits <br /> Door(s) j]Remodo� ❑Water pomege <br /> - Minneh8ha Creek Watarshed(�iatri�t(MCWp) <br /> �]wndow(s) Repair []Storm Damage 98202 Minnetonka Blvd <br /> •� pe9pheve�, MN 65391 <br /> •Q siding Q Resioration ❑Other.(specify) Phone: 952�?1-0590 <br /> � . Fax: �,52-471-068z <br /> ❑Ra�roof ' ❑ Flre Damage wunN minr�eh'ahacreek:�g <br /> ,.- - - <br /> OveralF Praject Des� tlon: �' � <br /> �Eatimated Ga�struction Valuatiun of Project(excludi g land) $ 3 x e 9 • — <br /> APPLICANT ACKNOWI�EDGEMENT: � <br /> . Agraes to provfde all information requlred or reqUested by the B�Ilding Departfient; <br /> � • CerGfies that the information supplled is true and conact b the best af his/her know�edge. The appllcant recognixes that they <br /> ' ' are solely re5ponsible for submitpn9 8 complgte application being aware tha�upon failure to do so,the staff has no altemative <br /> 4 but So releCt it urttil it le o0mplete: <br /> •� . � Some or all of t1te Information that you ere askad to provlCe on this appllcetion is ol8sslfied 6y State law es effhe�private or <br /> ,co�dentlal. P►ivate data is irrformeRion which generally eannot be givBn to the publlo but ca� bo given to the subjeGt of the <br /> � � data. ConfldenGal data.is informatian whlch penerelly Gannot be given to elther the public or the subjecC of tne data. Qur <br /> • purpoea and Intsnded use of thls Iniormauon is to annually updat� our fecords and record6 or other govemmonta) a9bnciss <br /> � re ulred b iaw_ ff u refuse to su I the Information,thrs a lication ma not be issued. <br /> ��APPlicanCs Sig�ature: �.S Date_ ^„ 3[ �a! �/� <br /> '��: � ( <br />