|
To: City Orono Page 3 of 3 2014-09-11 21:32:35(GMT) From: Andy Filer
<br /> 14 1
<br /> ..lLy uI %A um,
<br /> Building Permit Application for Maintenance / Replacement/ Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> ,..—
<br /> Mailing Address:
<br /> PO Box 66Pemtit nutttber; t d/�j ?�7
<br /> Crystal Bay,MN 55323-0066 D2ite receeivet /�j- !r/
<br /> Stroet Address: Reed by: /�2750 Kelley Parkway Plan review fee: ,GOrono,MN 55356krs HO*"
<br /> Total Fee: /5t5,0
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> m; -,pplio,,liow fe.w,mug.*b.eemplotc,J u,r..ii anu.ii ,cyubcU In(Vnnc,uVli InUSL be suomlttea
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: - 1 [ t
<br /> i Job Site Address: CLOD 4,e.�e`_y,,�ct k lv,L (.3 �5;,1i 1.�,?>�yA..�„�cv �tv `-rte G.hprv�`.
<br /> Will this be a Parade of Homes,Remodels Showcase Home or other splay 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 I AP LICANT INFORMATION:
<br /> Name: L-5(.,... —e____. 'u+ 5
<br /> State License# J,C 6-SjJ-- Expiration Date: 3//,
<br /> Lead Certification Number: " r 5--/ Expiration Date: � //S"
<br /> (for--A—,l.v... ,d. vv.:.4 .V/.
<br /> 4ofii cru pram-ry lam" / //
<br /> Phone: (cell) 6(/)- 7 y/5 3 (office) `'
<br /> Mailing Address: c.,)i ), f4er� L A....) ct,,+c;�( City: flyv.gp,...{t-,_ ZIP: 5-Sry�
<br /> Contact Person. '3 (,s Applicant is: C'"6.... rae`to j Homeowner (circle One)
<br /> Email and/or Fax: f,.4'., (R--,,t,� 1 0e-A 5,(arm
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: (.° �:- ' y Clk-k..( •
<br /> Phone(day): /
<br /> Address: . a W .,-ta'l&W l...i City:U(:>cq(0 ZIP: 5 S 37(
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: Any earth movement mayalso
<br /> ❑Door(s) MCWD review& require
<br /> 0 Remodel 0 Fire Damagepermits:
<br /> peRe-roof,asphalt ❑Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> (❑Rye roof,cedar 0 Restoration18202 Minnetonka Blvd
<br /> El Water Damage Deephaven,MN 55391
<br /> ❑Re-roof,other(specify) ❑Siding 0 Other:(specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> i /
<br /> EI Window(s) www.minnehahacreek.org
<br /> Estimated Construction Valuation of Project(excluding land) $ 6i Rr9Q�
<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 i .i a . all,,'at- . - ords and records of other governmental agencies required by law. If
<br /> you refuse to suPpl the r tl s. rr.:tion ma not be issued.
<br /> 401P-
<br /> Applicant's Signature: 4 i Date: , ®7
<br /> ,
<br /> Owner's Signature: Date:
<br />
|