Laserfiche WebLink
City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residentia! ONLY <br /> ��.ex �ir�d��s, �a�r�, �iding, r�-r�af. e��. — fl S�"� �TUR�L. EXP� �1 N� <br /> ��A tO Mailing Address: Permit number: a��'��`� <br /> �y PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received:- � �� /� <br /> , <br /> � � Street Address: Received by: ` <br /> y�, �1 2750 Kelley Parkway���� Plan review f : <br /> tqk�s����,� �\ Orono, MN 55356 ���� ` ' � <br /> Total Fee: ��3 ,�v <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: y�(� t� , <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 requi�ed with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonst�ates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: {�jU►� r5 b V ��S1Alrl <br /> State License# '�C �p Expiration Date: 3 -3 � - )q <br /> Lead Certification Number: NAT ��-L��d�� - o? Expiration Date: G'� -aq -�O <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) a-�-35 - 5 ,c� (office) �(�3y3y-�1.P31 <br /> Mailing Address: � ���; City: (J� �� ZIP: <br /> Contact Person: "�� Applicant is: Contrac / H eowner (Cfrcle One) <br /> Email and/or Fax: ' <br /> PROPERTY OWNER INFORMATION: <br /> Name: �Gfl d' �<'� C�S�l�C1�C1�1�1 <br /> Phone (day): a - a�� ��� � <br /> Address: S�m� City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: I ' tGS��� ba�l �e-+(1�lOC�P� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �emodel ❑ Fire Damage <br /> MCWD review 8 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�,O�p <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 e information,the a lication ma not be issued. <br /> .�, <br /> � ; <br /> Applicant's Signa r. Date <br /> Owner's Signature: Date: ( <br /> Last Updated:January 2016 <br />