|
. .
<br /> City of Orono
<br /> Building Permit Application for Maintenance / Replacement I Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) �-
<br /> �:�A\\ MailiPO Bo�r66� Permit number: �S ^ �
<br /> O�V� \
<br /> 1 Crystal Bay, MN 55323-0066 Date received: �l —� �j
<br /> ( � � Street Address: Received by:
<br /> 1 i�F ,�i 2750 Kelley Parkway Plan review fee:
<br /> `��C.S H���% Orono, MN 55356
<br /> �� Total Fee: l�� � J
<br /> Main: 952-249-4600 Fax: 952-249-4616 ti+,�srai.c:.o!ono r�r:_�,c � /
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be retumed. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: 7 �1 /��'«^� ��, �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No
<br /> ff yes,a specia/event permit is required with Police Qepartment and City Counci!approvaf 60 days pnor to the event. Shuttle bus service wil!be
<br /> required unless applicant demonstrates sufBcierrf on-site parking is available. Non-permitted events will not be a!/owed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: ��rrr�"< ,6vic-/'i-�-�< G`,'"���`�-
<br /> State License# ��'�3�i�/p Expiration Date: a3 �� a",•�
<br /> Lead Certification Number: y�,�� �,��v7U —/ Expiration Date: p-� � ��� —
<br /> (for work on homes fhat were constructed prior to 1978
<br /> Phone: (cell) �6i�) C�� -- �So G (office) �7�s� %-��"—��-c �
<br /> Mailing Address: /�%��v ��.,� s-s- City: �y,,,,�,,�,.� ziP: �-�-yyG
<br /> Contact Person: ,�f�.�'- /3, �;<<f„y���,�,,, Applicant is: ontrac o / Homeowner (Cirole One)
<br /> Emailand/orFax: ,«�<<:���„f�i✓ ,� �i�rr.-.-,rz./3.-.<�,-- C�'et---%T'rL. . �c�--�_
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �f� _�d�.�y .S��r��.jz c<
<br /> Phone(day): ��'s'1� �/y9 —c3s�G
<br /> Address: -7 yy ��,�� �� ,,� c��: �ze �r��=�� ZIP: s'�`3 f�
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall ro�ect description:
<br /> Type of Project: Any earth movement may also require
<br /> ❑Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�pennits:
<br /> ❑Re-roof,asphalt ❑ Repair ❑Storm Damage ��nnehaha 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 /> indow(s} �nn,vv�r.�;�innenahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ 6�va
<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 hislher 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 agenaes required by law. If
<br /> ou refuse to su 1 the information,the a lication ma not be issued.
<br /> ApplicanYs Signature: .� /S���.,��..��---- Date: fy ��
<br /> , --�
<br /> Owner's Signature: Date:
<br /> Last Updated:03/06/2013
<br />
|