2013-00394 - mechanical - Laserfiche WebLink

Home Browse Search

From:GOUNTRYSIDE HEATING & COOLING 763 479 2518 05l21l2013 13:52 #741 P.001/001 � � City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re•roof, etc.) �OA'O Mailing Address: Permit number: +y PO Box 66 Crystal Bay,MN 55323-0066 Date received: Street Address: ��by' � �C' 2750 Kelle Parkwa y�. G� Y Y Plan review fee: Orono,MN 55356 !�'ff5H0�� 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. lncomplete applications will be returned. (P/ease print) GENERAL INFORMATION: �5/� /1 j} � /' Job Site Address: (�O 1�;0{ �O Will this be a Parade of Homes,Remodelers Showcase Home or other Qisplay Home? Yes No ff yes,a specia/event permit is requlred wlth Police Department and CIry CouncA approva!60 days prior to the event. Shuttle bus servic�e wi!!be requlred un/ess applicanf demonsMates sulrcient on-site parking is availab/e. Non-permitted events will nof be allowed. CONTRACTOR/ PLICA T INFORMA'�ON: , Name: � .)Q•r✓�� State License# `� /'] Expiration Date: `") 3 O/ Lead Certification Number: Expiration Date: (ior work on homes tha!►+�ere constructed pr/or to 1978 Phone: (celI) —76 3 .��7 . 6 O c"� (office) Mailing Address: �"' �y / ciry: a q• Zip: 5-5 Contact Person: �Y, �e., Applicant is Contr tor Homeowner (CirclaOna) Email andlor Fax: , �/ PROPERTY OWNER INFORMATION: � n � � Name: E'.� � p•�'S O� Phone(day): ��'�_L,/& �3 � Address: _��'75 �'� � City: ZIP: S S�c��p Email andlor Fax: PROJECTINFORMATION: Overall ro�ectdescri tion: C ��''1� � �7` ��Ni-� Type of Project: Any earth movement m y also require � ❑Door(s) ❑Remodel ❑Fire Damage MCWD review 8 permits: ❑Re-roof,asphak ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) t8202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 Phone: 952-471-0590 ❑Re-roof,other(specify) ❑Siding ❑Other.(specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.oro Estimated Construction Valuation of Project(excluding land) $ 350�. pp APPLICANT ACKNOWI.EDGEMEN7: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and corcect to the best of his/her knowledge. The applfcant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative 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 confidentiaf. 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 intended use of this fnfortnatlon is to annually update our records and records of other govemmental agencies required by law. If ou refuse to su I the infor tion,the a on ma not be issued. Applicant's Signature: nate: �— l— � Owner's Signature: Date: Las!Updated:03/06/2013