|
Mar 24 14 _02: 53p Mike Norlander 61z 866 8074 p. l
<br /> � � City of Orono
<br /> Building Permit Application for Maintenance 1 Repiacement l Renovation
<br /> {No structural expansion. Only windows, doors, siding, re-roof, e c.)
<br /> �'- A, Mailing Address: Permit number: pZ�/ -�
<br /> � �O�YD . Crysta B�ay,MN 55323-0066 Date received: �'a "/
<br /> �. � StneetRddr�ss: Received by: �
<br /> ' � 2750 Kelley Parkway Plan revie ,
<br /> � .:
<br /> ' � Orono, MN 55356
<br /> �A� .. ,
<br /> � ��'�4�c�ni���L`::�,` To Fee � 7�. �-�
<br /> Main: 952-249-4600 Fax: 952-249-4616 � ���
<br /> This application form must be completed in fult and all required informa6on must be submitted.� �
<br /> Incomplete applications will be retumed. (P/ease print)
<br /> G�NERAL INFORMATION;
<br /> Job Site Address' i'�f;:>�' r- ,,�t,f..,"_- � k'`;- .
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ' No
<br /> If yes,e special event pemfit is required with Police Department and City Cou►►cil approvaf 60 days pr'ror to tFie event Shutlle bus service will be
<br /> nsqui�ad unJess applicant demonstrates sufficient on-site parlcing is svailable. lVon-permitted events wiH not be alJowed.
<br /> CONTRACTOR!APPLICAN7 INFORMATION: ;
<br /> Name: `t;' r`_��.� •`;s=-�_�./ ���. '.,--✓s L.'�. __ i_..(�L
<br /> State License# ' �� Expiration Date: �;'=�t'-,� ��� �
<br /> ��C (.•"3�Zi! '->
<br /> , ��, Expiration Date: �T; i (�, j 2A�i �
<br /> Lead Certification Number. ,�,_`/�'�.- i `;��:r � � — ! �� ,
<br /> (for work on homes fhat were consiructed prior to 9978
<br /> ( ) L-'t � Sc(_t; ..-:� ��
<br /> Phone: {cell) C;.:i'e:� f S�y_t:� Z.:-_�, offlce �-- "Z- - �
<br /> , � �- � Ci ^�.'� ZIP: >> ( (
<br /> Mailing Address: ��G:�c �-'�'-i+ -r-,-F�CL !� F_ ty'=-�-�---- �
<br /> Contact Person: �--�� ��;,� �; �,`'tCc.:_���-�.+ Applicant is: CContractor / Homeowner {cirda or�e)
<br /> , ---
<br /> ^ i��
<br /> Email and/or Fax: �tti���--v�...�:����F:,..r4_u.c::-:-��,�„r• �;,,rti: l.L.F-:..� [:-i'Z �.C�-i� - �.
<br /> ;
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ::.c-L.�' - `�'�C� ^-'-'' �����+
<br /> Phone(ciaY): c'�7� �; �L;;.� j C;� C� L-i,c"•�
<br /> Address: �C, e" � `_��=��=� �L�_ � City_ �%�-�_-�-.C,• ZIP: �j��=� i
<br /> Email and/or Fax: y�..c:�ti•L.�L-;,-'�:� . ,c,��:=:r.. •-�'���
<br /> PROJECT IN�ORMATION: Overall pro'ect descri tion:
<br /> Type of Project- Any earth movement may also require
<br /> � MCWD review 8 pertnits:
<br /> ❑ Door(s) B'F2emodel ❑Fire Damage
<br /> Min�ehaha Creek Watershed District(MCWD)
<br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage phapineaV952�71 0590
<br /> ❑ Re-roof,other(specity) ❑Siding ❑Other:(specify) Fax: 952-471-0682
<br /> ❑Window(s)
<br /> Estimated Construction Valuation o#Project(excluding land) $,'�`�- ������= �-
<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 appfica6on being aware that upon failure to do so,the staff has no aitemative but to
<br /> reject ii until it is complete;
<br /> • Some or all of the informaHon that you are asked to provide on this application is Gassified 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 subjeci of the data.
<br /> Confidential data is information which generalty 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 rec:ords of other govemmental agencies required by law. 1f
<br /> ou reiuse to su I the information,the a lication ma not be issued.
<br /> ApplicanYs Signature: �:'`-..--�-�-��"�..... =,--r-�'�---s-'. Date: G �i"Z-`; � �- -,t�!
<br />
|