Laserfiche WebLink
City of Orono <br /> Bu'ilding Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> O MailingAddress: � Permitnumber: ���.5"U�� <br /> �- �O PO Box 66 � - / <br /> Crystal Bay, MN 553 ��� Date received: �„� `d,.;` <br /> Street Address: �� '���� by� � - <br /> y�, ` 2750 Kelley Park y (�'/ �y/ � �L Plan review fee: ��. <br /> t �' Orono, MN 55356 /'`' ��-� <br /> �kEsxo�`�" aG 1`7 � c���:.��/� D�J� <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 sub itted <br /> Incomplete applications will be returned. (Please print) � �� <br /> GENERAL INFORMATION: � / <br /> Job Site Address: � �j p <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 approval 60 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: �N �JR�1� <br /> State License# '�('�(�( ,�a Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consfructed prior to 1978 � <br /> Phone: (cell) a (office) q �� <br /> Mailing Address: � City: � ZIP: <br /> Contact Person: Applicant is: �Contractor / Homeowner (Circle One) <br /> Email and/or Fax: � <br /> PROPERTY OWN INFORMATI <br /> Name: �V� ����I�C�-�� <br /> Phone (day): <br /> Address: C�C� '� � � 9 City: � ��� ZIP: �,��� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overal� project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage <br /> 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) $ 3 �3O <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 ' for tion is to a nually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I th i o 'on, t a lication ma not be issued. <br /> Applicant's Signature: Date: ���'1� <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />