|
City of Orono
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> '"� �� Mailing Address: �� ��'
<br /> � PO Box 66 Permit number:
<br /> ' � � "�,
<br /> Q '� Crystal Bay, MN 55323-0066 Date received: O�,S"�
<br /> 5
<br /> ��, � �� ,� 1 Street Address: Received by:
<br /> �- ' 2750 Kelley Parkway Plan review fee:
<br /> ��� `�� � ` ��� Orono, MN 55356
<br /> � +h,,t,����` �/�i�, 5�
<br /> . Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<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:
<br /> Job Site Address: �( 83 C cc S C v /��,.r� �- �d
<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 Po/ice Department and City Council approval 60 days prior 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 INFORMATION:
<br /> Name: .S ��r n �✓'��c.����u�i Cc����rkc�/o�, l.l,�
<br /> State License# �g����j�3 Expiration Date: � 3i �,j
<br /> Lead Certification Number: 3(; S �G�- � Expiration Date: � S
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) �/� -%�E ,�c'j:3 (office) �js;2-,3'�y- (,e� �
<br /> MailingAddress: � j �� ' Z S f- City: �-, �,,,,��r�,,, ZIP: S�' y�S
<br /> Contact Person: S���,�r� ��•, �c �,�a.� Applicant is: Contractor� / Homeowner �c�.��e o�e�
<br /> Email and/or Fax: ���,� �.�;�, � �,�n��,.��,; �. � �,�,,�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �eraJ •{- Sar, �r;� �r'ickso�
<br /> Phone (day): 9�,�- �J]/- 360 9
<br /> Address: ���� �..a S C c� t�o�r� � /�d City: p r G�� u ZIP: .�-SJ�'�
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall ro�ect descri tion: c: �i�� 'c
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) [�Remodel ❑ Fire Damage 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 s eci Phone: 952-471-0590
<br /> ❑ ( p fy) ❑ Siding ❑Other: (specify)
<br /> Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ S v���
<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 annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I the information,the a lication ma not be issued.
<br /> ApplicanYs Signature: Date:
<br /> Owner's Signature: Date:
<br /> Last Updated:03/06/2013
<br />
|