Laserfiche WebLink
. City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O A T Mailing Address: Permit number: ��" ��,3� <br /> �VO PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �S <br /> StreetAddress: Received by: /(�-� <br /> ti � 2750 Kelley Parkway Plan review fee: L'bt,lt�"l Ct �+� <br /> `�! L Orono, MN 55356 <br /> qkEsrio�`� , J�� <br /> Total Fee: � 3 a <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. (>.y�sc� � �y��s <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: 2 <br /> Job Site Address: J�S 5,�''���\� �pA� <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: �xx����n ��C.z�-;�,..�eN�C�►� <br /> State License# Expiration Date: <br /> Lead Certification Number: �� �Z_ � Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �lZ,. �� .S��Z (office) <br /> Mailing Address: � �S -- v � City: ZIP: �310� <br /> Contact Person: � Applicant is: ctor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �,� � �MJ MLrt k�' la <br /> Phone (day): (,$'/, !p. S"7 3� <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: tl ��lZ. i✓� ��� ' C�u�- �-p � �C�ee,2� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: <br /> ❑ Re-roof,asphalt �Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <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) $ � �, <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 informatio ich generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this infor o 's n Ily update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I t nf , he lication ma not be issued. <br /> Applicant's Signature• Date: S �r <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />