|
�._� �
<br /> City of Orono `'�" �����) ��
<br /> ' Building Permit Application for Maintenance / Renovati
<br /> (windows, doors, siding, re-roof, etc.) ��25 So
<br /> Mailing Address: Permit number: �O/�-OOJ`.3J`�
<br /> O�,L,�,�0 PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: -/ -/Z-
<br /> � �.,,. � �t��
<br /> .� , �, � Street Address: Received by: �c.ra�
<br /> �y', ;�:
<br /> �'.� � ��� ^�� �ti 2750 Kelley Parkway Plan review fee: ��/o� -BOJ�3
<br /> �9,xEs��� Orono, MN 55356 ��/� �S
<br /> Total Fee: G�J
<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. (P/ease print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: //�/ (',`l-c,v.� � �, - s� 1�� ,.,��.� �w :� ,---��_��,� �,-til.`.,' � 5 3� �
<br /> Will this be a Parade of Homes, Remodelers howcase Home or other Display Horhe? ❑ Yes [�NNo
<br /> If yes, a special event permit is required with Police Department and City Counci/approva/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: ��,h �;,��,t C',.-�.-�;f���1-��, �
<br /> State License# -����z z �.�,. � Expiration Date: .�v���
<br /> Lead Certification Number: Expiration Date: �
<br /> (for work on homes thaf were constructed prior to 1978
<br /> Phone: �l2- `1� '�� �`t� `( (office) � �Z-`3�: r- ��J Y� (cell)
<br /> Mailing Address: c �;�� �„�,_ �. City: L+ �� �`0._y,t ZIP:
<br /> ,..t� ��
<br /> Contact Person: '"S =. Applicant is: Contractor Homeowner (Circle One)
<br /> Email and/or Fax: �� C�—k„��4�nk,r�,,,,,�.���.,, < <,,.--� _ �';, 5 Z-31� l -L��tS c
<br /> ,�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: '� � ����
<br /> Phone (day): G�-Z - �L- � _-�S Z I
<br /> Address: //`� C/.��-✓ �ius� Dr„� �_ City: (.,/:.�,. � _�.` ZIP: ���5'�
<br /> Email and/or Fax �
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&permits:
<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 eci Phone: 952-471-0590
<br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Overall Project Description: - ,, ��;�_ /.'� r ����,� �0.`� _ � -i`/�' v - J �kj,�
<br /> Estimated Construction Valuation of Project (excluding land) <' ����
<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 information which generally cannot be given to the public but can be given to the subject of the
<br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
<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 su I the information,the a lication ma not be issued.
<br /> ��
<br /> ApplicanYs Signature: �,� ;/i�" � - Date: ��.�-� l `�` Z� i Z_
<br /> Last Updated: 08-09-2011
<br />
|