Laserfiche WebLink
i:ity of urono <br /> E3uilciang Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O Mailing Address: Permit number: �� /�—d l 026 <br /> �- ^/\ PO Box 66 <br /> � Crystal Bay, M N 55323-0066 Date received: /a—� �o—f <br /> Streef Address: � Received by: <br /> % :�� 2750 Kelley Parkway / Plan review fee: <br /> ,`� �� Orono, MN 55356 'p��I�y� <br /> \�'�fSFi� � � <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) -i� 3�` <br /> GENERAL INFORMATION: <br /> Job Site Address: � Ca 5- �-D�CU f Q� S'�'r��' <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a special event permif is required with Police Department and City Council approval 60 days prior to fhe event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Lc�v-sov� Co1/����-1'i0 �-� <br /> State License# BL,����6 Expiration Date: 3 3/ l fp <br /> Lead Certification Number. ��,'�'-. �24 ��-�( Expiration Date: -r�' `� /� T <br /> (for work on homes that were constructed prlor to 1978 <br /> Phone: (cell) ( _a p�g (office) Z-- 5q�.-� � —' <br /> MailingAddress �h,� � �� City: �( ZIP: cj'� o <br /> Contact Person: � Applicant is: ontractor / Homeowner (Clrcle One) <br /> Email and/or Fax: .� ��dln � �j -�- , �'� <br /> PROPERTY OWNER INFORMATI N: - <br /> Name: �r� c7lV� 1J ei [ `�Gv�c�,4yl,�%� <br /> Phone (day): «(( Ce(Z- ' l$'-- '3�{(� ( J <br /> Address: Z GOdtiC4 T '�'`C��� c�tY: Gro Q ZIP:T'J�Q 1 <br /> Email and/or Fax: �-Fr-q,;h o y-� 0�,�i-k'�" . LD Uh <br /> PROJECT INFORMATION: Overall roject description: <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) �Remodel ❑ Fire Damage MCWD review 8�permits: <br /> ❑Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Rescoration ❑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) $ 3 t�� <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 corred 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 altemative 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 Gassified 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 govemmental agencies required by law. If <br /> ou refuse to su 1 the information,the a ication ma not be issued. <br /> Applicant's Signature: Date: �� �� l <br /> Owner's Signature: Date: <br />