Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
. . . � , . <br /> City of Orono <br /> Building Permit Application for Maintenance/ Replacement/ Remodel - Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL Ek <br /> MailingAddress: permitnumber: �� � -�n� � <br /> ���0 PO Box 66 cr <br /> Crystal Bay.MN 55323-0066 � `1� Date received: � ' — � o <br /> � } � Street Address: �� Received by: �_� <br /> �. � 2750 Kelley Patkwa� Plan review fee: <br /> `��,� a �� Orono,MN 55356 I � �� <br /> Kt s H o � ���"'�� Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.o o.m�.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete appllcatlons will be retur ed. (PI ase print) <br /> GENERAL INFORMATION: � ��� � {� <br /> Job Sita Address: ' "� G -, [� �,ts�t� %J � � tJ `" <br /> Will this be a Parade cf Homes,Remo elers Show ase Home or other Displ y Home? Yes o <br /> If yas,a specia!event permit is requrred with Police Department and City Council approva160 days prior to the event. ShutNe bus 'ce wiN be <br /> reyuired unless applicant demonsbates sufficient on,site parking is available. Non-permitted events wiU not be eNow . <br /> CONTRACTOR/APPLI ANT I ORMATIO : `, <br /> Name: (,�E'i f� �� ���d �L � <br /> State License# Expiration Date: <br /> Lead Certification Number. Expiration Date: <br /> (for work on homes that were consbucted prJor to 1978 <br /> Phone: (ce�q - � .- 332- (ottice) fo/Z - 3� 3� � Z <br /> Mailing Address: � �/ City: � iy f ZIP: ''�,� <br /> Contact Person: , Ap licant is: Contra r ! Homeowner co-a.o�e� <br /> Email and/or Fax: � � _„� ' �, <br /> PROPERTY OWNER IN ORMATION: � � � <br /> Name: �! �� ��� ,fl�! � <br /> Phone da <br /> Address: Y). � �, � City: �,q/J�� n� ZIP: �3 �� <br /> Email and/or Fax: � <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Projeet: Any earth movamont may also roquire <br /> ❑Door(s) emodel ❑Fire Damage MCWD review 8 permits: <br /> ❑Re-roof,asphalt Repair ❑StoRn Damage Minnehaha Creek Watershed DisVict(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orU <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> --__ -- — <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the infoRnation supplied is tn.ie and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon fallure 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 annual update our records and records of other govemmental agencies required by law. If <br /> ou refuse to su ( f m►ation, ication ma t be issued. <br /> ApplicanYs Signature: /` � � Date: <br /> Owner's Signature: ) � Date: <br /> Last Updated:January 20 <br />