Laserfiche WebLink
r , City of Orono <br /> Bui{ding Permit Applicatyon for Maintenance { Repfacement I Remodel —Resident3aS t�N�Y <br /> e�. '.�k�, a; <br /> � ��, Marlin Address: i L G'1'7-Ob y Z,� <br /> g Permit number <br /> ,�f ���a\"� Grystal Bay,MN 55323-0066 r Qate receive d: �2�I 1� <br /> � 1 <br /> � Street Address: Received by: �� <br /> y \j� 2750 Kelley Parkway Plan revievu fee: �L�'�-�-Q� � <br /> � � � Orono.MN 55356 ,,i --7 <br /> ��kE s H o�j' Total Fee: 3 <br /> �__� � � � � <br /> Main: 952-249-4600 Fax: 952-249�3616 ��-_. ,rr; �";_��_ � � <br /> This application form must be completed in full and all required information must be submit�Q 5/�l 1 � <br /> Incomplete applications will be returned. (Please print) <br /> v <br /> GENERAL INFORMATION: � <br /> � IC � <br /> Job Site Address: ' � �� �'�t� � ti'�'��� ��� �'�� <br /> Will this be a Parade of Homes, Remodelers Sh wcase Home or other Display Home? ❑ Yes No <br /> If yes, a special event permit is required with Pohce Depar(ment and Crty Council approval 60 days pnor to fhe event. Sl�utffe bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: � I �d^ �^ �o ti S-� l`��,t �"r z,n , �V�� � - <br /> State License# C � �. 2 2 � G r Expiration Date: �- ,j j - 1 �' <br /> Lead Certification Number: �{�-�-- C r. � v cs--=-�. Expiration Date: -�-�-=-=�-� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) t� / ;� ' �D , - 2, S( (office) <br /> Mailing Address: �� ; ,) -�¢�.t . City: � �crrt tt���� '� ZIP: �� ;� <br /> Contact Person: �, � , Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: �, a� �� � '�� ' � �� ���'� <br /> PROPERTY OWNER INFORMATION: n <br /> Name: j� � E�; � tt r e� ��r ��! ��/�..� � �''� - <br /> Phone (day): �� �� .PO �� �� �� 'p �'�� � <br /> Address: C `�� •r 1,c,! r t ��1 v� City: �/D/'� ZIP: � J,�.�� <br /> Email and/or Fax: t�i ;� ' � �� ' � ' <br /> PROJECT INFORMATION: Overall project description: ,[. t%►�2��� r � �" ' j <br /> Type of Project: Any earth movement may also require <br /> MCWD review 8�permits: <br /> ❑ Door(s) �Remodel ❑ Fire Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) ��vwv _~�inn���� ---- -� <br /> Estimated Construction Valuation of Project (excluding land) $ �'� nxl �'r� <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 information which generally 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 records of other governmental agencies required by law. If <br /> ou refuse to su pl the information,the a lication ma not be issued. <br /> Applicant's Signature: �'��r � � Date: <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />