Laserfiche WebLink
3 <br /> ' � � City of Orono ` `�y <br /> Building Permit Application for Maintenance I Renovation <br /> (windows, doors, siding, re-roof, etc.) �: <br /> �O� Mailing Address: Permit number: ��1�d� � <br /> PO Box 66 <br /> Q Q Crystal Bay, MN 55323-0066 Date received: /Q � /� a <br /> °� ��. #Y <br /> �� •�-�� s, Sfreef Address: Received by: <br /> � <br /> � ; ' ' � 2750 Kelle Parkwa t' <br /> '�'.� � o Y Y Plan review fee: � <br /> 9'kESH�4� Orono, MN 55356 n �, <br /> Total Fee: �{��, � � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us v ��. <br /> � <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: ��� � tv�g j ��., 2,� �� <br /> Will this be a Parade of Homes, Remodelers Showcase Ho e or other Display Home? ❑ Yes ❑ No �� <br />�� I f y e s,a specia l even t permi t rs require d wit h Police Department and City Council approval 60 days prior to the event. Shutt/e bus service will be ;� <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed. <br /> Y� <br /> � CONTRACTOR/APPLICANT INFORMA�ON: ,� <br />�•� Name: . C.�s ���.�{-�2 ��,JS T2cr c' °� <br />�`'` State License # � <br /> �v{o3 i�7� Expiration Date: � 3 - i� ; <br /> � <br />�x` Lead Certification Number. Expiration Date: � <br /> (for work on homes fhaf were constructed prior to 1978 � <br />�: Phone: ��,�-c./'j�_ �"1 c l, (office) (cell) � <br /> Mailing Address: ,$'i c(,� �'�n�S�<� �4-- City: e1�p(`- W ZIP• S 3�� � <br />` ` Contact Person: Sd E-�� Applicant is: Contrac r / Homeowner (Circle One) �' <br /> Email and/or Fax: <br />� ' �� <br /> PROPERTY OWNER INFORMATION: � <br /> Name: n , � <br /> f�-+ �C�-L� ;� <br /> ;;� <br /> Phone (day): ,�; <br /> Address: ��d U B�S l�r., �-� City:�,pk,r e� �ia-yF�,�' ZIP• � <br /> Email and/or Fax '.� <br /> � <br /> PROJECT INFORMATION: �� <br />, ` <br /> Type of Project: Any earth movement may require <br /> ❑ Door s ❑ Fire Damage MCWD review& ermits: <br /> ( ) ❑ Remodel Minnehaha Creek Watersh d District(MCWD) <br /> �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 = <br /> ❑ Re-roof, other(specify) ❑ Sidin Phone: 952-471-0590 � <br /> g ❑ Other: (specify) Fax: 952-471-0682 ��. <br /> ❑Window(s) www.minnehahacreek.orq K� <br /> •.i <br /> Overall Project Description: (_��, ��=�- � �' �g- „� ��_�� � <br /> � <br /> Estimated Construction Valuation of Project(excluding fand) $ --7� g� �- 's <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 alternative <br /> but to reject it until it is complete; <br /> <: <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. Confidenfial 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 is to annually update our records and records of other governmental agencies "' <br /> re uired b law. If ou refuse t su the information, the a fication ma not be issued. ;•, <br /> ApplicanYs Signature: � Date: J��Z�f // ..� <br /> Last Updated: 08-09-2011 � <br /> <. , ... v� <br />