Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
Sep-22-2010 01.22 PM American Building Contractors 952-707-9925 1/1 <br /> -13300 s <br /> I <br /> City of Orono I <br /> q d ID <br /> Building Permit Application <br /> Melling Address: Permit number. Maio — FS <br /> 0 <br /> (73,0:4'c).• PO Box 88 <br /> Crystal Bay, MN 56323-0066 Date received: '?4/a/3)//7 <br /> ���"" Received by: <br /> o. ,,! 4.' <br /> Street Address: <br /> ''I J��' r``'' 2750 KelleyParkway�, , � �. � Plan review fee. <br /> _: -4 • Orono,MN 55358 <br /> Total Fee: /�i� j 1f%/►/(� 9 % , <br /> Mein: 852-249-4500 Fax: 952-248-4616 www.ci.orono.mn.uL <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 INFORMATN: <br /> Job Site Address: on Lk.), ,\E1%).3' it () Or0{1.O �N S�3 SZc <br /> Will this be a Parade of omes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes,a special event permit is required with Police Department end City Council approval B0 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/APL�INFORM ION: <br /> �,c+.,�., jv.� <br /> Name: .v`_ C -•4.4. <br /> State license# 2"4) llaqIra Expiration Date: <br /> Phone: 9v. 7a-1- 9 ri (office) (cell) <br /> Mailing Address: z-4 0 �,t .k,r:.r� Y'LC) I 0 0 CI t�+fwt1. r 1 t— <br /> ZIP: 5 35 7 <br /> - <br /> Contact Person: Applicant Is: ontracto / Homeowner prolong) <br /> Email and/or Fax: C\6)-1 6. A .1L -MN • C 0 re-- <br /> PROPERTY <br /> rPROPERTY OWNS FORMATION: <br /> Name: Q.�\t, IV\ A 16.1 <br /> Phone(day): (a k/ —K\4 - -- 1`'% <br /> Address: Q L'30 )• \Q,,J Or r City: C'D•lt Q ZIP: 53 3 5—r•=, <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Protect: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> U Windows) cp.Repair {Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 56391 <br /> ®Siding in Restoration . 0 Other:(specify) Phone: 952.471-0580 <br /> Fax: 952-471-0882 <br /> 'Re-roof In Fire Damage www.minnehahacreek.org <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ 7-5f06.2-1 <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 V" <br /> but to reject it until it Is complete; C*' (A1 <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 ' Z� <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 to supply the Information,the application may not be issued. <br /> Applicant's Signature: <br /> Date: l rf-\0 <br /> N ' Ragcr� m' , i1 <br /> , -.i <br />