2013-01305 - siding - Laserfiche WebLink

Home Browse Search

� � � . '�� ; � � City of Orono `� � �. Buildi�ng Permit Application for Maintenance / Replacement / Renovation � :f � � (No structural expansion. Only windows, doors, siding, re-roof, etc.) � �O . `O Mailing Address: Permit number: � 1V PO Box 66 `� Crystal Bay, MN 55323-0066 Date received: � � Street Address: Received by: a� � ' y�, ` 2750 Kelley Parkway Plan review fee: � �.� �' Orono, MN 55356 `qkESHOR� Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No ,,=s; If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/AP:PLICANT INFORMATION: Name: }� "{-flr t��`v� State License# , � �� Expiration Date: - ��,( � Lead Certification Number: �� ;� � a � 6 - + Expiration Date: '� -3-- �� �{• (for work on homes that were constructed prior to 1978 � Phone: (cell) (office) Mailing Address: `� C� � City: 4 �� I �u- ZIP: `-'�' � Contact Person: � � � (�-�'�Q _ �j y Applicant is: Contractor / Homeowner (Circle One) �' ;. 5.x, Email and/or Fax: ¢. s� �`"` PROPERTY OWNER INFORMATIO • �'.. Name: �� v�— G��t �S 0� � Phone (day): '� Address: � � � Cit : ZIP: �Y � V �i �. �� Y �(/u h r Email and/or Fax: 4 PROJECT INFORMATION: Overall project description: � ��- Type of Project: Any earth movement may also require �: MCWD review 8�permits: ,� ❑ Door(s) ❑ Remodel ❑ Fire Damage � �� ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) '� 18202 Minnetonka Blvd ��:`� ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 t ,� � Phone: 952-471-0590 "� "€.` ❑ Re-roof, other(specify) Siding ❑ Other. (specify) Fax: 952-471-0682 � ❑ indow(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) , G u �`:; APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Building Department; � Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are � • solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or ,_, confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. &- Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and � i �� intended use of this information is to annually update our records and records of other govemmental agencies required by law. If � �� ou refuse to su I he informati n, a lication ma not be issued. k'.` ApplicanYs Signature: Date: �.Q;l Owner's Signature: Date: G�'� �� Last Updated: 03/06/2013 ,�� : r�; �.,. _ _ _� . ,. _. .�