Laserfiche WebLink
�� � � �� <br /> . � City of Orono ���-���`� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> /'� Mailing Address: Permit number: �l '-'�7 <br /> ��^/O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 7—a�� <br /> � Street Address: Received by: <br /> -�5.�, � 2750 Kelley Parkway Plan review fee: �� <br /> � � Orono, MN 55356 � � <br /> !�'�fSNv � /�/ <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: � GC Z I �C�C �e�[il��� �U `��, �� <br /> Will this be a Parade of Homes, Remodelers howcase ome or other Display Home? ❑ Yes �No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus se ice will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMAT ON: �� � <br /> Name: { ���.,�. � !`•.•C.�� cn <br /> State License# � G Expiration Date: ' ���.jr � <br /> Lead Certification Nu er: /�,/ `— s _ Expiration Date: ' Z� � C <br /> (for work on homes that were constructed prior to 978 <br /> Phone: (cell) (, , (office) <br /> Mailing Address: � � `� City: �v�.1, ZIP: c <br /> Contact Person: �, i ^ Applicant is: ractor Homeowner (Circle One) <br /> Email and/or Fax: • � vL ' c, : � ' <br /> PROPERTY OWNER I�IFORMATI N: <br /> Name: �? �i� <br /> Phone (day): ( _ , <br /> Address: � G'r�rt,e S� Q��'" IZ� C�ty= !�' e�'b�'1 0 ZIP: <br /> �� Z�� � <br /> Email and/or Fax: �— <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: <br /> ❑ Re-roof,asphalt �epair ❑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.or4 <br /> Estimated Construction Valuation of Project(excluding land) $ (� 1 S', a <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 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 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 annuall update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the i ' n�t e a not be issued. <br /> ApplicanYs Sig u�" Date: '� -' � <br /> Owner's Signature: Date: <br /> Last Updated:03/06l2013 <br />