Laserfiche WebLink
City of Orono <br /> Builc�ing Permit Application for Maintenance/ Replacement/ Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> O Mei1iP0 Boxr66 . � � , Permit number: _'� - f"� ��- + <br /> �- �� �15�,� ��'' _ <br /> Crystal Bay, MN 55323-0066 Date received: r - '' —/� <br /> � .� rYj .�� <br /> Street Address: Received by� �`. q <br /> y�, G�� 2750 Kelley Parkway Plan review fee: <br /> t Orono,MN 55356 �� u �� <br /> �+�ESH��� Total Fee: � <br /> Main: 952-249�600 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 wlll be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �j a o <br /> Will this be a Parade of Homes, Remode Showcase Home or other Dlsplay Home? Yes No <br /> It yss,a speclal event permlt Is requ/red with Polfce Deparbneni and Clty Councll epprova160 days prlor to the event Shuttle bus s rvice wil!be <br /> requlred uMess applicant demonstrates sufHclenf on-s/te parking(s avallable. Non permitted events wiN not be a!lowed, <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ��tsion LLC. <br /> State License# a��o��pZ7 Expiration Date: 3�3(� (� <br /> Lead Certification Number: ���Z�����Zc�_ { Expiration Date: c��fr��� <br /> (for work on homes that were constructed prtor to 1978 <br /> Phone: (celq ((o l 2� S9�l-'�I Z(�`t (office)�(Q(2� �-(Cv 2 -�(Oov <br /> Mailing Address: � C�y� w Z�P� 5S 3 <br /> Contact Person: Mike 51,,��4,ey„«•,� Applicant is: Contra / Homeowner �ci�a.or�� <br /> Email and/or Fax: �,,�;ke�9Z�.v;s�n�r.�►n_ eow. <br /> PROPERTY OWNER INFORMATION: <br /> Name: �sh a,,.a ���-; M�.� �� <br /> Phone(day): <br /> Address: I'�l�i[� S�kc�vu�xr�� Rr�. C�tY� anovu� Z1P: 553�1 <br /> Email andJor Fax: L� � Q�;�, Co YH <br /> PROJECT INFORMATION: Overall ro�ect descri tion: c�c 2 t�«l� S I� -'� � �. Pk„r. �o,�•, C��I,�y, <br /> Type of ProJect: . Any ea�th movement may alao require �.��. <br /> ❑ Door(s) �Remodel ❑ Fire Damage <br /> MCWD revlew&permlts: <br /> Re-roof,as halt ❑Re air Minnehaha Creek Watershed District MCWD <br /> � p p ❑Storm Damage 18202 Minnetonka Blvd C > <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑R�roof,other{speclfy) ❑Siding ❑Other: (specify) Phone: 952�7'1-0590 <br /> Fax: 952-471-0682 <br /> �Wndow(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(exclud(ng land) $��DO <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide aIl information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of hislher knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no aftemative but to <br /> rejed it until it is complete; <br /> • Some or all of the infonnation that you are asked to provide on this application is dassified 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 rally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this inform io is ann ally update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the' af n,t a lication ma not be issued. <br /> Applicant's Signature: � _ _ Date: //� �� /Co <br /> Owne�'s Signature: Date: <br /> Last Updated:January 2015 ��G���"/ / /� �� <br /> ��.��' � / <br />