Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
City of Orono <br /> , Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windaws, d�ars, s�ding, re-rc�of, et�. - NO STRUCTURAL EXPANSIONj <br /> j-��� Mailing Address: Permit number: °~ <br /> PO Box 66 <br /> i �� Crystal Bay, MN 55323-00 Date received: — �- , <br /> i <br /> � <br /> � � � Street Address: 7 �� / � Received by: <br /> \�� 1� 2750 Kelley Parkwa� ���Lj � Plan review fee: LrB-�-�-t <br /> �`�i �� ' Orono, MN 55356 <br /> ��Kr.s r�o�; <br /> Total Fee: ��/ i1 (� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � U O <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: � � �� ' �= K�-� - <br /> Will this be a Parade of Homes, Remodelers Show se Home or other Display Home? ❑Yes ❑ No <br /> If yes, a special event permit is required with Police Department and City Counci/approval 60 days pnor to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP�ANT I�IF0J�IAATI/ON: <br /> Name: ` ! •'�� `�.��� iJ-�-- <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �(Z ='�,c%_ ` -�p` (office) , <br /> Mailing Address: , City: IP: S" (`j <br /> Contact Person: � ; , Applicant is: Contractor / Homeowner° �c���ie one� <br /> Email and/or Fax: � "���� .� j - � <br /> PROPERTY OWNE�. FOR AT1pN: <br /> Name: -. ;L% �.1..,L <br /> Phone (day): ' � <br /> Address: 6 � City: ZIP: �S` /� <br /> Email and/or Fax: ����� � ��) . � � ` <br /> ` � tcx,.J, <br /> PROJECT INFORMATION: Overall pro�ect descripti�d�i �Lt.dL� ��l�,�- � � <br /> Type of Project: A y earth movement may also require <br /> ❑ Door(s) ['�Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(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.orq <br /> Estimated Construction Valuation of Project(excluding land) $ , <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide all information 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 are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative 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 annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su the i formation,the a lication ma not be issued. <br /> ,a <br /> "',�• y <br /> Applicant's Signature:� �� ' ' ' ��- Date: � %L �C> �i <br /> � �� � ��� � Date: � /L �, <br /> Owner's Signature: ' <br /> Last Updated:January 2016 ���!�� � �K �� <br /> G,% � � � / <br />