2011-01303 - roofing - Laserfiche WebLink

Home Browse Search

I � �� � � � 4 � Cit of Orono �1 � 2 � � � �� � y � �. � � . Building Permit Application for Maintenance / Renovation � °� ��.,�; (windows, doors, siding, re-roof, etc.) �e� - � Mailing Address: ��.' �,L 0,(�\ PO Box 66 Permit number: O// -�,� � � � Q Crystal Bay, MN 55323-0066 Date received: �� ,; � a � � �.� �� F� StreetAddress: Received by: r �'�, t �'�y �� 2750 Kelley Parkway Plan review fee: � �`�gESKo�`'� Orono, MN 55356 � — 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. �s Incomplete applications will be returned. (Please print) � GENERAL INFORMATION: , �' Job Site Address: -�Q v ,,��z lf�� Will this be a Parade of Homes, Remodelers Showca Home or other Display Home? ❑ Yes � No � If yes,a speciaf event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be "� require unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �:; ;� CONTRACTOR/APPLICANT INFOF�MATION: '� Name: ��( �i��✓S T1�G � State License# �� (�� Expiration Date: �_��_�.��a Lead Certification Number: �qT,�p��` Expiration Date: M�}yS �o%/ � (for work on homes that were constructed prior to 1978 � Phone: 95 5 -�� '-� 3 (office) cell Mailing Address: �;,.,.� City: p ZIP: � 3- (- ) � Con tac t Person: d,r � � Applicant is: Contractor / Homeowner (Circle One) � Email and/or Fax: � � 'mi PROPERTY OWNER INFOR�TION: � ,� Name: � ' � Phone (day): �tS� �,7?� a �y7 � Address: / - 1�/.Y' �r/a6Gts ,t7w�/ �dCi l City: (��r�NN(� ZIP: . �� Email and/or Fax ' � � PROJECT INFORMATION: Type of Project: Any earth movement may require � ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: :� Minnehaha Creek Watershed District(MCWD) ``� �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd s� ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 :;� ❑ Re-roof, other s eci Phone: 952-471-0590 `= ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 � ❑Window(s) www.minnehahacreek.orq "� ,p Overall Project Description: � , � Estimated Construction Valuation of Project(excluding land) $ � � .�.�� , � APPLICANT ACKNOWLEDGEMENT: ;� �� • Agrees to provide all information required or requested by the Building Department; :g; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant 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 -"� �^� confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the r� f ' data. Confidential data is information which generally cann�ot be given to either the public or the subject of the data. Our '; purpose and intended use of this information is to ually pdate our records and records of other governmental agencies � �� re uired b law. If ou refuse to su I the informat' ,the lication a not be issued. '� `` , � ApplicanYs Signature: � Date: �(��?l��v� �` Last Updated: 08-09-2011 ;� � .a�_ .__.��. „ . ,_. _,._.._,.,rt�