Laserfiche WebLink
City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: ,2„C)/a—000 c05 <br /> /O O.�O Cr CryBox 66 f o?� <br /> Crystal Bay, MN 55323-0066 Date;received: <br /> w !, <br /> A �, a, Street Address: Received by: <br /> „4,4 o~ 2750 Kelley Parkway Plan review fee: <br /> "gkESHo¢6' Orono, MN 55356 <br /> Total Fee: /35..50 <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: Jcz- <br /> «� ((J7 P/ <br /> v <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes .eoms. <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: njre i /Irl- At,f�c i63 <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: l07a--&(e0 f 6/4(7 (office) " - ?i it...P (cell) <br /> Mailing Address: / � g0 5� iprf //f City: J/./o,- /4,40 ZIP: .5s3 <br /> ?2 <br /> Contact Person: it,G tgvPwh,e),--7 Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: >Zi 6fir / eev IS <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) KRemodel 0 Fire Damage MCWD review&permits: <br /> 0 Re-roof,asphalt Minnehaha Creek Watershed District(MCWD) <br /> p ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> • <br /> ❑ Re-roof, cedar 0 Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) ❑ SidingPhone:: 952-471-0682952-70 <br /> 0Other: (specify) Fax: <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overall Project Description: g_Qytip V 3 p 11wr5 twk 64.5evt4erd/s uPpvct w/ /Vr cf_,. <br /> Estimated Construction Valuation of Project(excluding land) $ 9 5-0c..) <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 infor is annually update our records and records of other governmental agencies <br /> re•uired b law. If ou refuse to s_401 .,t.1Ti�T- e a.•lication ma not be issued. <br /> Applicant's Signature: Date: -1-7 Z <br /> Last Updated: 08-09-2011 <br />