Laserfiche WebLink
City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O�O Mailing Address: Permit number: �-U(S � 1 � � <br /> � PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: i L�► <br /> L <br /> `�� Received b � <br /> � � /Street Address: ` �,�� y� <br /> ti�,� � � �I� I� 2750 Kelley Parkway \�� �;'�� Plan review fee: R ✓� ('�t,�C� <br /> t L I � Orono, MN 55356 /� �� � �� � <br /> '�fSH�� � <br /> � �J Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 �1www.ci.orono.mn.us � <br /> This application form must be completed in full and all required information must be submitted. � �r,� ��r� <br /> Incomplete applications will be returned. (Please print) �« <br /> GENERAL INFORMATION: <br /> Job Site Address: _ ���j� C(�i�p P.�• � • <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ❑ No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days pnor 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 INFORMAT/�IOI�: <br /> Name: K.��� ��5� h 1_J�� <br /> State License# 0 Expiration Date: S•} , <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consfrucfed rior to 1978 <br /> Phone: (cell)4 i Z Z (office) ' • <br /> Mailing Address: �� City: ZIP: <br /> Contact Person: v� Applicant is: Con ra or / Homeowner (Circle One) <br /> Email and/or Fax: � <br /> PROPERTY OWNER IN ORMATION: � I� <br /> Name: 5 /h t <br /> � <br /> Phone(day): q Z. � <br /> Address: City: ZI P: <br /> Email and/or Fax: � <br /> 1 <br /> PROJECT INFORMATION: Overall pro�ect description: � �� �'' <br /> Type of Project: y eart move ent may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage <br /> 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) ❑Siding ❑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) $ <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 ar ask d ,fo provide on this application is classified by State law as either private or <br /> confidential. Private data is inf mation w ch nerally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is informatio� w ich ge rall can t be given to either the public or the subject of the data. Our purpose and <br /> intended use of this informaf ly pd o r records and records of other govemmental agencies required by law. If <br /> ou refuse to su I the infor � af m not be issued. <br /> ApplicanYs Signature: � Date: . � � <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />