Laserfiche WebLink
City of Orono <br /> Building Permit Application for Maintenance/ Replacement/Remodel — Residential ONLY <br /> willuo' . ,,,„,- - NO STRUJCTURAL. EXPAtk,_ <br /> (� Mailing Address: bci'/l-0070 f <br /> �0/V0 I PO Box 66 <br /> Permitnumber: <br /> �,�}/ Crystal Bay, MN 55323-0066 Date received: inn ''-. 9-/-7 <br /> i i Received by_ v l <br /> Street Address: <br /> \ / 2750 Kelley Parkway Plan review f <br /> �/ ., % Orono, MN 55356 T 1 <br /> -`�drstr�� Total Fee: ' [ <br /> Main: 952-249-4600 Fax: 952-249-4616 <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: O'er �/� Sc��Pr�Job Site Address: lS 7 ✓�E Ta t / ite oI'Ot <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes lNo <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus seill ce 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: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNERjNFORMATION: <br /> Name: e tit4M fotkl'ISo/J j1/4/IE_ <br /> Phone (day): [I,44- -3A - .7 f y-s- 6/J "�1%9'3--7/e. <br /> Address: vs-75 [,wL(A-= ri)/J tLific-G.a--- City: ()tooZIP: 5 s:TS y <br /> Email and/or Fax: Ig -a.- e-gAz . e Vvl <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> E Door(s) ElRemodel 0 Fire Damage MCWD review&permits: <br /> 0 Re-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> 0 Re-roof,cedar 0 Restoration ❑Water Damage Minnetonka,MN 55345 <br /> ❑ Re-roof, other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> fig Window(s) <br /> Estimated Construction Valuation of Project(excluding land) $ 1.-1,a00. <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 annua)ly update our records and records of other governmental agencies required by law. If <br /> you refuse to supply th-;, formation, the a4 .:tion may n� be issued. <br /> Applicant's Signature: 41110'-�4011r -Pdtilligr .GL. - Date: / J- ----- 9 (>1 <br /> iirr <br /> Owner's Signature: ,,74 - i . Q4--4 <br /> Date: ( of �-�;7 7 <br /> Last Updated:January 2016 �' <br />