Laserfiche WebLink
, <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> � (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: ���3 ` bD � 7� <br /> �v 0,� PO Box 66 <br /> Q il � Crystal Bay, MN 55323-0066 Date received: .J-/� �3 <br /> �a �j �, i Streef Address: Received by: uS <br /> �� "N*, G� 2750 Kelley Parkwa �\� Plan reviewfee: <br /> t9g�s_Ho�`''� Orono, MN 55356 �� <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: � �2� <br /> Job Site Address: �� ��� ���-� � . �-� .. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> /f yes, a special event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus rvice ill be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wrll not be allowed. <br /> CONTRACTOR/APPLICAN INFORMATION: <br /> Name: {�' �J(,�,�� <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were constructed prior to 1978 <br /> . ---- � <br /> Phone: _ (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��_k�I� ���� <br /> Phone (day): �— <br /> r� iz� Z-z �', ���s'�- <br /> c�t �' �` <br /> ress: _?`7� �Z �4--� �T. I{� y'����- ZIP: S SJ�� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> �Door s `�Remodel MCWD review&permits: <br /> � ) ❑ Fire Damage <br /> � � Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other s ecif Phone: 952-471-0590 <br /> ( p y) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> Window(s) www.minnehahacreek.orq <br /> Overall Project Description: (�y�,t�fi� kC� w;4( � � � f �,Q,w �� <br /> Estimated Construction Valuation of Pro ect(exctu ing land) $ ��_����J��� <br /> , <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to 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 in ' ' y ca not be given to the public but can be given to the subject of the <br /> data. Confidential data is in rmation whi�,h.-cfen rally ca ot be given to either the public or the subject of the data. Our <br /> purpose and intended use of is informafion � to ann y update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to u I the' ormati ,the a lication ma not be issued. <br /> ApplicanYs Signature: V /� Date: �1 � , � � <br /> Last Updated: 08-09-2011 <br />