Laserfiche WebLink
, City of Orono �� ��z� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O�O Mailrng Address: Permit number: c7D(3-- Od ! <br /> PO Box 66 <br /> Crystal Bay, MN 55323-00 Date received: <br /> Street Address: Received by: <br /> y�, � 2750 Kelley Parkway �I��`�� Plan review fee: <br /> ��,L Orono, MN 55356 d,�+ � <br /> `qkBSH� �'J � q�. �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: ' � ,,ct.�c_.� U �-u �� �� 11 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes -�Vi-o <br /> If yes, a special event permit is required with Police 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/APPL�ANT INFORMATION: <br /> Name: ' `J r�,�.�►o-1i,Q tQ- �fC, lol�l — 6Lt�n E�"�- <br /> State License# �— Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed piior to 1978 <br /> Phone: cell) C1j�- �U -(o p� (office) 5,,4,.,.-�.�_ <br /> Mailing Address: �� p - � J,[ City: L ZIP: <br /> Contact Person: � f, i Applicant is: Cont ctor / Homeowner (Circle One) <br /> Email and/or Fax: ��� <br /> PROPERTY OWN FORMATION: � <br /> Name: �c��1w��t-C 1`l� lJ��loC� <br /> Phone (day): C��, -� �,-l� __ (o-� nt� <br /> Address� � y, ��� City:���� �, ZIP: 5����_ <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel �e Damage MCWD review 8�permits: <br /> ❑ Re-roof,asphalt �air ❑ 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(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ LU.Dt�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 th � atio , he a lication ma not be issued. <br /> Applicant's Signature: - % Date: / - � ` �� <br /> Owner's Signature: �, Date: G/ - � '��� <br /> Last Updated: 03/06/2013 <br />