Laserfiche WebLink
City of Orono <br /> ' Building Permit Application for Maintenance / Replacement/ Remodel - Residential ONLY <br /> a�_P_ ,n�:� . :�: Ff_�4nr. ��'.-�t�nr. �'tG. , '-�f.JCT' �.-r- �Xf��: <br /> _ — ,. <br /> ' Mailing Address: Permit number: "�-��- % ;� � � <br /> �����'�, PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: —Z -� <br /> 1 <br /> ! ` ' Received by: 1� <br /> � �; , � Street Address: <br /> � �`' :� <br /> 2750 Kelley Parkway Plan review fee: <br /> �`�� �/ Orono, MN 55356 <br /> ����f S H����.! ,,.���—'�J�� <br /> ___.-- Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 <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: �� v � �-.j G� �.n � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> lf 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 suHicient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLIC T INFORMATIO <br /> Name: ���Q ��-�.�Z�V\ <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) / Z_ � � - 3 �,5� ' (office) <br /> Mailing Address Z " C� � �ti C o�ti City: � �•� � ZIP: �y � <br /> Contact Person: 4N � Applicant is: Contractor / omeowner (CircleOne) <br /> Email and/or Fax: _S� r� cJ o �t� � �1��+ • ���� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �`� h N�� C:��� I =Z-l� <br /> Phone (day): � Z- � �� - 3�5� r� <br /> Address: Z �� ,�. L�, �o•,,,� (��`J City: �<,v�a ZI P: S���J � <br /> Email and/or Fax: �c ;3�,,� Jo �5� <� � ✓tic.. , L �r <br /> � <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �-f2emodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt �.ftepair �Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration �Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> �.aA(indow(s) <br /> Estimated Construction Valuation of Project(excluding land) $ '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 informatiori is to annuall u ate our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the� formation,the a ic tion ma not be issued. <br /> Applicant'sSignature: ----Date: � � Z� " �b <br /> Owner's Signature: ` Date: <br /> ��6 - z� � l� <br /> Last Updated:January 20R6 J <br /> \\. � <br />