Laserfiche WebLink
City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: •"Perrriitinumber /2-©4.t© �3 <br /> ©� C Box 66 �g <br /> • \ Crystal Bay, MN 55323 0066 '`Dateteceived. U�� <br /> Received b <br /> a i''-'. a, Street Address: y <br /> 1� I)• <br /> ,.,1x,it,�� GDZ <br /> titi 2750 Kelley Parkway Plan <br /> :reviewfee: <br /> r�ESH04� Orono, MN 55356 <br /> Total Fee �� <br /> Main: 952-249-4600 Fax: 952-249-4616 .ci.orono.mn.us <br /> This application form must be completed in full nd all required information must be submitted. <br /> Incomplete applications wiI be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: <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: ,.../72-, :/_-, 47/ �z.,,-Af vGfi�.c� <br /> State License # �c•- �/'5%74/ Expiration Date: 73,7.•_ .<,/./ .z- <br /> Lead <br /> 1 /_�jam` <br /> Lead Certification Number:, / ,:c55- <br /> J,x 9___y • Expiration Date: ziz y'/3 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: r76.3 .-- 27 f l� (office) f... - (cell) <br /> Mailing Address: / / City: ZIP: <br /> Contact Person: /j L/, 0A, Applicant is: ontrac or7 / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Jam_/7L-;/Z/s9 c/ e>-/.7;t/ • <br /> Phone(day): ;e3 - - //,,,ti/57c7 a>1,2`9/d y7,5' <br /> Address: Cit 1P; <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> E Re roof, asphalt E Repair Minnehaha Creek Watershed District(MCWD) <br /> p ❑ Storm Damage 18202 Minnetonka Blvd <br /> I:: Re-roof, cedar IIIRestoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re roof, other(specify) ❑ Siding E Other: (specify) Fax: 952-471-0682 <br /> XIWindow(s) www.minnehahacreek.orq <br /> Overall Project Description: ,,/rzC �.r7,�.(� , <br /> �//'7 e.2.,,--"" 012--) 7.e) CJS <br /> S- <br /> Estimated Construction Valuation of/Project (excluding land) $ /,._ e, v- <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 application being aware that upon failure to do so, the staff has no alternative <br /> but to 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 <br /> data. Confidential data is information 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 /> required by law. If you refuse toisuppiy he information,the.pplication may not be issued. <br /> Applicant's <br /> PP ' Signature: t �%%'�� ---- /�� Date: /4.--; /..K..- /-e-/Z— <br /> Last Updated: 08-09-2011 <br />