Laserfiche WebLink
City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> i (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> Mailing Address: Permit number: 2d i (o a <br /> O PO Box 66 <br /> Crystal Bay, MN 553 3-0066 Date received: <br /> Street Address: Received by: <br /> yF 2750 Kelley Parkway -�— J Plan review fe <br /> L <br /> `gkFSHOOrono, MN 55356�� <br /> T Fee: <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 infor ation must be submitted. <br /> Incomplete applications will be returned. (Pleas rint) <br /> GENERAL INFORMATION: -f <br /> Job Site Address: -I ` rt F c�w6. ��1 ► a 01 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes LYNo <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: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNERIN ORMATION: <br /> Name: &,-,( R. I7 r o <br /> Phone (day): - �bk 3 , O <br /> Address: S r It, ►-Jc,- City: ZIP: SS 35 <br /> Email and/or Fax: 0 VJ,1 ap vee 1 C�n^ ii <br /> PROJECT INFORMATION: Overall project description: -� ^ �e Y Qo-�u v-�?� <br /> ;Door(s) <br /> e f Project: Any earth movement may also require <br /> 914emodel El Fire Damage <br /> MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> �// 15320 Minnetonka Blvd <br /> El Re-roof,cedar E!Kstoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ So I o o _`- <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 /> you refuse to supply thli4riformation,the applicatiorj may not be issued. <br /> Applicant's Signature: Date: U ►�R Z ) 10l <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 �� // <br />