Laserfiche WebLink
; City of Orono <br /> Building Permit Application for Maintenance / o tion <br /> (windows, doors, siding, re-roof, etc.) , <br /> Mailing Address: ermit n ber: � a � <br /> �0,� PO Box 66 <br /> Crystal Bay, MN 55323-0066 ate rec i�ed: — �� <br /> O��;';,.,, , O <br /> �a ' 'r � �, Street Address: eceived by: <br /> .�L���� �"�'_�G� 2750 Kelley Park y P n revie fee: J , S <br /> ,.9�� ��IT" r <br /> ,_\ xESKo4� O ono, MN 5535 a / - D0 <br /> To I Fee: � <br /> Main: 952-249-4600 Fax: 952-249-4616 .ci.orono. n.us <br /> This application form must be completed � full d all requi d informati n mu be ubmitted. <br /> Incomplete applicati s will be returne . (Please int) <br /> GENERAL INFORMATION: <br /> Job Site Address: 3-- L}lzr i-;�-,� <br /> Will this be a Parade of Homes, Remodelers Sho ase H e or othe Display me? ❑ Yes No <br /> If yes,a special event permit is rec�uired with Police Departme t and City ouncil appro al 60 days pridr to the event. Shuttle bus se ice will be <br /> required unless applica demonstrates sufficient n-site park� g is availab . Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INF RMATION: <br /> Name: 'o �' L�� -^�5�� � <br /> State License# �j �, :����� Expiration Date: 3 - 3� - �W <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes ihaf were construcfe rior to 1978 <br /> Phone: �5 3- y"1�-y f I$ (office) �, i z �5 c �{ 3�� (cell) <br /> Mailing Address: ���3 �°,�,St � � City: �ov�.nclL ZIP: 5 S 3� <br /> Contact Person: � S�„��.� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �}�sr,,� �T� 3;�� �c� non�'+e.C'�Re� ►1�� <br /> PROPERTY OWNER INFORMATION: <br /> Name: L,11� � � F''o�-� in��Rz /� �f <br /> Phone (day): -��3 '�7c 3"1'1 t;, � `L �v <br /> Address: ���j� ���� ��� <br /> Email and/or Fax � 1 f�i � �i�1`� � <br /> ��(� "�l <br /> PROJECT INFORMATION: f��,{ 'y�� `F/��r� <br /> Type of Project: � t v��vat V t1 �, �� <br /> ❑ Door(s) ❑ Remodel ❑ Fire Da �� ,t An� �y►► � <br /> v�rv �VC, <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm [ <br /> ❑ Re-roof, cedar �.Restoration ❑Water[ <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: � /J' ' ` <br /> ❑Window(s) �� ` <br /> Overall Project Description: � �_ Q� �� <br /> Estimated Construction Valuatio of Project(excludir <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested <br /> • Certifies that the information supplied is true and corrE <br /> are solely responsible for submitting a complete applic <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to <br /> confidential. Private data is information which generally , <br /> data. Confidential data is information which generally cannot be given to either the pubiic or tne su��ec� u� ���C �.,a�a �,u� <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to s e information,the a lication ma not be issued. <br /> ApplicanYs Signature: ' Date: S-2.3 -I� <br /> Last Updated: 08-09-2011 <br />