Laserfiche WebLink
4 • City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ,q�� <br /> �O�VO Mailing Address: Permit number: <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> Kelley <br /> 2750 G� Y Parkwa Y Plan review fee: <br /> t <br /> ESHO� Orono, MN 55356 <br /> Ak <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 7' <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: 7 <br /> Job Site Address: ,�5 g o <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �'No <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# C 2'-{ 7 Expiration Date: 2 of <br /> Lead Certification Number: 4J,4T iy 3 e'L — I Expiration Date: � �?d <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) &(Z �'Gp (office) <br /> Mailing Address: ( r aj) `� ✓e �J City: /�. a� ZIP: 5 <br /> Contact Person: Yom( �;�, .� _ Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: ll4� P r— (_,"cso l---- <br /> Phone (day): Z_1 79 �3 _ <br /> Address: ?S f�a �� w` awr City: /�/`, ; ZIP: �sJ <br /> Email and/or Fax: n <br /> PROJECT INFORMATION: Overall project description: "J'tr— <br /> Type of Project: Any earth movem ni may also r6quire <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <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) $ 7 rC70 <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 the info rmatio ,th licationma not be issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />