Laserfiche WebLink
k �+ �V 1` l���J V���� <br /> ��'`1 -�� � �'��4r �`���� City of Orono <br /> Building Permit Application for Maintenance/ Replacement / R�model — Residen�ia! ONLY <br /> (i.e. windows, doors, sidiR�g, re-roof, etc. — N� �7RUCTURAL EXPANSION) <br /> MallingAddress: Permitnurnber: 1 -` ����1 ' <br /> ��� PQ Box 66 - - - <br /> Cryst21 Bay,MN 55323-0066 Date[eGeived: <br /> Street Acldr�ss: 'Received by: <br /> �, �' 2750 Kepey Parkway Pian r�view fee:, <br /> `� � Orono, MN 55356 <br /> j'���s�o��' Total�'ea. `� � ��. ,�� <br /> � Main: 952-249-4600 Fax; 952-249-4616 www-ci.orono mn.� <br /> This application form must be completed in full and all required intormation must be submitted. <br /> Incomplete appllcations wlll be returned. (Please print} ��: v� <br /> GEN�RAL 1NFORMATION: ����� 1 �1�� nr, � <br /> ,�ob Site Address: L. r r�_i <br /> WIII this be a Parade af Hames, emodelers Showaase Home or other Display Home? 0 Yes o <br /> /{yes,a specia!event p�rrnit is repulred with Po!!Ce Deparfinenf and City Councll approva160 d8ys prior to fh9 evenf. Shutfl9 bus seivic wlll ba <br /> required unless�pl�Iicant dempnstrates s�clent on�site parking is availabl6. Non-�ermif�ed Bvenfs wi!!not Ue alloWed. <br /> C�N7RACTOR 1 APPLICAN7 I FORAAA ION: �(� <br /> Name� �6.,' G i�25 �� �i1 � 't Q. �t��^�� <br /> 5tate LEcense# �, L � � �3 Expiration Date: � <br /> l�ead C�rtlfication Number� '� ���- Expiration Dat�: ���-�,4 <br /> (for work on homes that�vere conslructed priar to 7978 <br /> Phone: (Cell) ��t` �` (office) (�S�-- �� <br /> Mailing Address: � (� �� City' ri ��ZIP' �'J � � <br /> Contact Person: � Applicant is: ont actor / Hameowner �a��e o�e� <br /> �mail andlor�ax: <br /> PRORERTY bWNER INPbRMATIaN: <br /> Name: �QF\ �,.��lC�p� - <br /> Phone(day): . �S`�-� 1..�,� �� S'�� <br /> Add ress: City: ZI P: <br /> Emafl and/or Fax: <br /> pROJECT kNFORMATION: Overall ro'ect descri tion: <br /> Type of P�oject: Any earth movement may glso require <br /> MCWD review 8�permits: <br /> ❑Door(s) ❑Remodel ❑ Fire�amage <br /> Re-roof,as halt ❑Re air ❑ Storm Damage Minnehaha Creek Watershed Districti(MCWD) <br /> � P p 15320 Minnetonka B�Vd <br /> ❑ Re�roof,cedar ❑Restoration ❑Water Demage Minnetonka, MN 55345 <br /> F'horte: 952-A71-0590 <br /> []Re-roof,other(specify) S�iding [�}Other.(specffy) Pax: 952-471�06$2 <br /> � <br /> �Window{s) www.n(L[�ehahacr�� .orq <br /> �stim�ted Constructlon Valuation of Project(exduding I�nd) $_���U <br /> APPLICANT ACKNOWLEDG�MENT: <br /> . Agrees to provlde all informatlon required or requested by the Building Department; <br /> • Certifies that the information supplied is true and c�rrect to the best of his/her knowledge. The applicant recognlzes that fhey are <br /> saiely responsible for submitting a camplete application being aware that upan failure to do so,the staf�has no altemative but to <br /> reject it until it is complete; <br /> • Some or all af fhe infqrmation that you are asked to provide on ti�is applicatton is classffled by Stafe law as either private or <br /> confi�iential. Private data is Informaiian which generglly eannot be qiven to the public but can be given te the subjeet of tha data. <br /> Confidential data is inirrmstlon which generally cannot be giv�n to either the pubNc or ihe subject of the data. Qur purpose and ' <br /> � Intended use of This information is to annually update our recards and records of other governmental agennies required by law. If <br /> oE� refuse to su f the information,#h a lication ma nat be issued. <br /> Applicant's Signature� Date: `! 1" <br /> Owner's Signature: Date: <br /> I�ast Updated:January 2016 <br /> LB/Z0 �Jdd '�D�d JNIQIS �l 6ZZbb�9T59 ZZ�ZT 9ZBZ/I£/50 <br />