Laserfiche WebLink
��°� <br /> City of Orono ,� � �;� <br /> • Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) - <br /> Mailing Address: Permit number: <br /> Og,�,j�.O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> �a 1 <br /> ,� � � � �, Street Address: Received by: <br /> ,�, �\�y- ti 7 <br /> .�s,� � � � 2 50 Kelley Parkway Plan review fee: `. <br /> �kESHo4� Orono, MN 55356 `; <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. (P/ease print) <br /> GENERAL INFORMATION: " <br /> Job Site Address: � Z- � �� <br /> Will this be a Parade of omes, Remodele Showcas,e ome or other Display Home? ❑ Yes No i.� <br /> If yes,a special event permif is required with Police Department and ity 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 /> �.;'. <br /> CONTRACTOR/APPLICANT INFORMATION: ` � <br /> Name: �� �' �d�� ' <br /> State License# - , '� '� Expiration Date: � j 3 � <br /> Lead Certification Number: ���"-_ .�Ll �_� Expiration Date: �� � <br /> (for work on homes that were constructed prior to 1978 � <br /> Phone: — - '�,� (office) (cell) <br /> Mailing Address: �(�, � � City: �,cj.�ZIP:� s� <br /> Contact Person: � � �L �-y Applicant is: Contrac � / Homeowner (Circle One) � <br /> Email and/or Fax: '��>3 _ � (�, - '7 ` � <br /> _� <br /> � <br /> � <br /> PROPERTY OWNER IN RM TION:, � <br /> Name: � l . ��', <br /> Phone da - �� <br /> � y�: �. e�� a � <br /> Address: t�(� � ,, City: � ��,��, . ZIP: l��j!_? ' <br /> � <br /> Email and/or Fax �' <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require �� <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar Restoration ❑Water Damage Deephaven, MN 55391 ° <br /> Phone: 952-471-0590 � <br /> Re-ro f, o�her(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 � <br /> .� � ❑Window(s) <br /> www.minnehahacreek.orq <br /> Overall Project Description: �y� � Y.�ti� x <br /> Estimated Construction Valuation of Proj c (excl g land) $ � <br /> ;; <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative �� <br /> € <br /> � but to 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information i to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I th inf rma ' ,the a li tion ma not be issued. <br /> ApplicanYs Signature: / �` � Date: �� L� <br /> Last Updated: 08-09-2011 <br />