Laserfiche WebLink
� � <br /> _ . �� <br /> Cit of Orono � �� <br /> Y <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ,��, ` Mailing Address: Permit number: �!y— � <br /> l�l� PO Box 66 <br /> Crystal Bay,MN 553 - Date received: 7/�"�� <br /> � Street Address: J � Received by: T <br /> ti�, �� 2750 Kelley Parkway �I Plan review fee: 002•/ <br /> t,qk��`�fl�� Orono, MN 55356 ��_O,� 7! <br /> Total Fee: <br /> Main: 952-249-4600 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 will be returned. (Please print) <br /> GENERAL INFORMATION: . <br /> Job Site Address: �7D0 �jay���:,e. ��'� Drotio il,dJ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> If yes,a special event permit is required with Police Department and City Council approva160 days prior 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/APPLICANT INFORMATION: <br /> Name: Nit/� �or��S LC..G <br /> State License# gG.r;S'y037 Expiration Date: �-3/— Zo/6 <br /> Lead Certification Number: �,g.7--_�-lf��� J Expiration Date: f_�� — �/9 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �/Z 787—SZ$S (office) �SZ� Z8$�3 7�/6 <br /> MailingAddress: �� � �j., u, oyB Ci : ; Z�P: S 30 — <br /> Contact Person: �,�.�LC ,�j,,,, Applicant is: Contractor / Homeowner �ci.�iao�e� <br /> Email and/or Fax: �e� ��ie�� . Ca,,,� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ..�r�,v,� ,��c abS <br /> Phone(day): <br /> Address: �70U s1,�,�.-e/,1,� ,Qi--. City: Oro.,o ZIP: SS3�'/ <br /> Email and/or Fax: <br /> PROJECTINFORMATION: Overall ro�ectdescri tion: ��Cva. ac/q�i` v►� <br /> Type of Project: Any 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 /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 <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) $_�DEJ�/0• -- <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•faiture 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 I t a' the a lica' ma ot be issued. <br /> ApplicanYs Signature: Date: �`—��y <br /> Owner's Signature: Date: <br /> Last Updated:03/O6/2013 <br />