|
_ F �.
<br /> -�
<br /> _ �-
<br /> City of Orono � �
<br /> � �r
<br /> �
<br /> �.:A � w.4_ ���.
<br /> ` ` �' Building Permit Application for Maintenance / Renovation �� g:
<br /> (windows, doors, siding, re-roof, etc.) '-q�
<br /> Mailing Address: Permit number: �/l- �
<br />' g,0,�. PO Box 66
<br /> � �;, �
<br /> Crystal Bay, MN 55323-0066 Date received: / q�
<br /> .� �' , � Received by:
<br /> y�,;�:� �,� Street Address:
<br /> �',�, � t ��'� G,�' 2750 Kelley Parkway Plan review fee:
<br /> � Orono, MN 55356
<br /> �EsxoS`` l� �� ��
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us '��
<br /> ��
<br /> This application form must be completed in full and all required information must be submitted. �
<br />. , Incomplete applications will be returned. (P/ease print) �
<br />''p� GENERAL INFORMATION: s > �.
<br /> Job Site Address � �' � ��`�.� � � � �r,..�� ���F� J/2 a��ea /"�'a�' ��_�3� � �
<br /> � e�
<br />�. Will this be a Parade of Homes, Remodelers Show se Home or other isplay Home? ❑ Yes No
<br /> !f yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus servrce will be
<br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed.
<br /> t;
<br /> .�;,,;
<br /> CONTRACTOR/APPLICANT INFORMATION: ''�
<br /> Name: � /�a�r��'�,�'� y L or� ��� ~ �
<br /> State License# Z�� Z � ��� �' Expiration Date: ��-���'� � ,�
<br /> Lead Certification Number: Expiration Date: �
<br /> (for work on homes that were consfructed prior to 1978
<br /> Phone: ��Z _ �� a_ -��Y � (office) g5Z - `��r - �?�$ j (cell) �'
<br /> Mailing Address: go� S �� ],.L ,,� City: �, 1� ZIP: S� ��g �,� �
<br /> 4' Contact Person: �ua.� �u c,�,oc S dti( Applicant is: Cont ctor�J / Homeowner (Circle Onef �
<br />;; _�_.___�.
<br /> �
<br />,�,: Email and/or Fax: �� ����p L�_t� � � . � o � ,�
<br /> ��
<br /> �':
<br /> PROPERTY OWNER INFORMATION: �
<br /> Name: ��',.��. C-o;�-�
<br /> �
<br /> Phone (day): (0 1 Z - ZS t - �s�3 � �'�
<br /> Address: ��S STvf�13S i�A�/ I,Z�a.c� City: �126/�� ZIP: '� a 3 S la
<br />`= Email and/or Fax
<br /> - PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review&permits:
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD)
<br /> �-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �
<br /> Phone: 952-471-0590 ��
<br /> ❑ Re-roof, other(specify} ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 '`
<br /> www.minnehahacreek.orq �:
<br /> ❑Window(s) �
<br /> ,�
<br /> Overall Project Description: ,�p – T1�,,,� �9 ,f'��� �;� � �,,.,l-? �� - �,�;, y��
<br /> Estimated Construction Valuation of P ect excludin land $ `��
<br /> 1 ( 9 ) �' Zo_no G� �
<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 appfication being aware that upon failure to do so, the staff has no alternative ,�
<br /> but to reject it until it is complete; 4�
<br /> s
<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. Confidential data is informafion 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. I# ou refuse to su I the information,the a lication ma not be issued. �
<br /> �.�
<br /> g � ��
<br /> ApplicanYs Signature: -F- � Date: �p�ZCo � a� ��:
<br /> —T
<br /> Last Updated: 08-09-2011
<br /> '`:i
<br /> _.9 . r-t�
<br />
|