Laserfiche WebLink
, 1 � lo�� <br /> C�ty of Orono <br /> �� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roaf, etc.) <br /> �,� _ <br /> Maifing Address: � <br /> � ��� � PO Box 66 � Permit number: ��� —��-��j <br /> ��` Crystaf Bay, MN 55323-0066 ; C1ate received ' / —�3 <br /> � —_. _ <br /> ° Received by: <br /> � � � � StreetAddress� � --------� <br /> , ;�, ,� �� 2750 Kelley Parkway ' Plan review fee: <br /> F �� �,� ����f Orono. MN 55358 � -- ----� <br /> ; L '�E�St�oE,.- � <br /> - ___ � Total Fee: ����/.� <br /> # Main: 952-249-4600 Fax 952-249-4616 1�.���:� ����� n��= C� <br /> ' This application form must be completed in full and all required informatian must be submitted. <br /> Incomplete applications wifl be returned. (Please print) <br /> GENERAL INFORMA710N: � - '�'� T <br /> i � � <br /> Job Site Address: ��> ;� r`; <':��rJ ,JL`'{� � <br /> , ' ----- ------ --- ___ <br /> Will this be a Parade af Homes, Remodelers Showcase Name ar other Display Home? ❑ Yes � No <br /> /f yes a special event permit is r�equired with Patice Department and City Gouncil ap�roval 60 days prior to the event. Sh«ttle Uus service�vill be <br /> reqiiired unless applrcant demonstrates sufficfent on-site parkmy is availaGle. Non-permitted events{roill not he allo�.verl <br /> CONTRACTOR/APPLICAN7 INFORMATION: <br /> Name: <br /> -----..__.__.---- --__----�_._--._ ____.__._____.._______...........__....._..----------____.._ ___ <br /> State License# Expiration Date: <br /> -- ------..__ _----------------__ _ __ _ ___. <br /> Lead Certification Number: Expiration Date <br /> --------------------- — <br /> (for wark on homes that were constructed prior to 1978 <br /> Phone: (cell) (office} <br /> -- __— __------------ ----_ __ _ __ _. _ __ <br /> Mailing Address City ZIP <br /> _.__.___.,_�_.__.____��. __.__._ ___ ___-_._ _..._____. <br /> Contact Person Applicant is: Contractor / Homeowner (Circle One) <br /> Email and!or Fax: � � � <br /> PROPERTY OWNER INFC�RMATIdN: <br /> , <br /> Name: � � � �� � �� ` � � <br /> --, `'._� 7'Z� _�" � �_�`� t_ � <br /> _ _ _ __ <br /> ( Y}� �-- -- —___ - <br /> Phone da �� I _ ��� - � �-� � <br /> � Address: � � / � Cit : {� ZIP: � �� �£- �-J ' <br /> � --.�:.�'—�Xv����� ,_.n,•� �;�� Y ! C-F��t�v7"� �J � r <br /> � Email and/or Fax --�_�s.�_���-�_�.z.`�� .�___��*1 ;. r�,, �:�! __._ yP",�, _ �. <br /> .;, t:;. �_ �_ __ <br /> � PRUJECT INFORMATION: Overall praject description_ _ __ __ _ <br /> � _ �_ � ___ _.__ ..__ _.----- -_-, <br /> ; Type of Prqject: � Any earth movement may also require <br /> �;Daor(s} �niT Z ��-1�i� Q Remodel ❑ Fire Damage �CWD review& permits: <br /> I ; Minnehaha Creek Watershed District MCWD <br /> � ❑ Re-roof.asphalt ❑ Repair ❑ Storm Damage � � <br /> 18202 Minnetonka Bivd <br /> , ❑ Re-roof. cedar ❑ Restoration �Water Damage � Deephaven. MN 55391 , <br /> f ❑ Re-roof other(sp�cify) �Siding ❑ Other (specifyj � <br /> Phone 952 471-0590 <br /> ! Fax 952-471 Q682 <br /> �.1.7'►'�txsP1=(h� /Z4c_____.__ [�VVindaw(s) � �., ;, � ,.:�, �� �r i �� <br /> A!l/� rhhlS�'S _-- -____ ------ ___ __.___..______.—__._.._ . ___ _ _ . - —_— _.___.._ <br /> Estimated Construction Valuation of Praject(excluding land) � <br /> APPLICANT ACKNC?WLEDGEMENT: <br /> �_�-------------______.___._..______..._____.__ _ �._ �_.___._.__. _ _ __ _ <br /> i • Agiees to provide alI information required ar requested by the Building L�epartment, <br /> ' • Certifles that the information supplied is true and correct to the best of his/her knawledge. The applicant recognizes that they are : <br /> solely responsible for subr7iitting a compEete applicatian being aware that upon failure to do so, the staff has no aftemative bui to �' <br /> reject if until it is complete; <br /> • Some ar all of the ii7forrnatic�n tha! you are asked to provide on this applicatian is classified by State law as either private :; i <br /> � confidential Pnvate data is informatian which gei�erally cannot be given to the puhlic but can be given ta the subject of the dat�s <br /> ' � Confldential data is ir�forr77ation wiiich generally cannot be given ta either the public or the subject of the data. Our purpose an;, <br /> intended use af this informatian is ta annually update our records and records of other governmental agencies required by law It ' <br /> ; you refuse to s�app�the inforrnation,the�plication may not be issued �� <br /> Applicant's Signature: t Date: <br /> ��JrJ; % - r <br /> Owner's Signature� �j � ,��'�� t� �% C�at� �� -� �� - ° <br /> as!�.�' 1 r7�, �i> > ;�!i�� � � <br />