Laserfiche WebLink
City of Orono Ai• <br /> 3ca`� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: o�13 ` 0iDcO5 <br /> /*) <br /> /IdPO Box 66Crystal Bay, MN 55323-0066 Date received:Street Address: Received by: 66-5- <br /> 2750 Kelley Parkway Plan review fee: .2 3Q• 10 CpdOrono, MN 55356.ktsHosTotal Fee: 020 13 - D IO <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 information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: r( ix,--) \;I Q"; D C \ vim. _ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? CI Yes N❑ 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: +. SV-.e09. 3J,ASC—vThe" ..moi �sv ,� pc`a Li <br /> State License# c 9 0 0`- -7 1 ( Expiration Date: 3-31- I (-( <br /> Lead Certification Number: ti W Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) Co l. --) y ()Li —1 Ca (office) ?Co - 31 `J - 1 OS —? <br /> Mailing Address: S4.4 Do E.:4._e e s Lt/- City: S ZIP: 5 `j 1 <br /> Contact Person: u As2Applicant is: Contractor / Homeowner (circle One) <br /> Email and/or Fax: �� Y ,�,� , ni g1-,e cR 0 0 <br /> PROPERTY OWNER INFORMATION: <br /> Name: 2(L ��,-� :c ✓-"N <br /> Phone (day): COI - (., c),-1 <br /> L 1 <br /> Address: q ,c.-k \Ji Q w'Q City: Ovov\C ZIP:.56----3e- <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <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) ElSiding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ d-i 6a <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 .nfo ation,the a lication may not be issued. <br /> Applicant's Sig Date: l°/?c /l <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />