Laserfiche WebLink
City of Orono <br /> Buifding Permit Application for Maintenance/ Replacement/Remodel — Residential ONLY <br /> (i.�, �,��r��iv�rv�, cic�crre�, ������, r�ryr��+�, ��t�. � �i� ���4��"�'��'���. ��.�e�����."��3� <br /> /��� ,'` Mailing Address: Permit number: � �' ` :�C'�'�' ' <br /> 1Y PO Box 66 � <br /> j� � Crystal Bay, MN 55323-0066 Date received: -`�- �`>` 1(.�- <br /> Street Address: ' �� Received by: �`�T=; <br /> t a , <br /> ��, �� 2750 Kelley Parkway Plan review fee: � ��'���-k C' � �2 �`-��-- <br /> �!� .. `l� �' Orono, MN 55356 /I � <br /> �kFSHO,/ �(� � Total Fee: �� <br /> Main: 952-249-4600 Fax: 952-249-4616 vwvv�✓.ci orono mn us `�1/� ��'� <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 Add ress: �g�� rcx����w Vjly�oF � <br /> Will this be a Parade of Homes, Remodelers Sho cas Home or other Display Home? ❑ Yes [�7No <br /> If yes, a specia/event permit is required wiih Police Depariment and Ciry Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficieni on-site parking is available. Non-permitted events wi/l not be allowed. <br /> CONTRACTOR/APP ICANT INFORMATION: <br /> Name: �Q,�115�an �L.LC� <br /> state �icense# i� 63q 0��- Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were construcfed prior io 1978 <br /> Phone: (cell) q,ja.- ���. 35�� (office) (�l� �6�. �{00(� <br /> Mailing Address: � L�,� � w City: z� ZIP: ,�,jg/ <br /> Contact Person: ���±� (b��n.�a Applicant is� - ontra r / Homeowner (Circle One) <br /> Email and/or Fax: p���L � �����o�M� �oM <br /> PROPERTY OWNER INFORMATION: <br /> Name: 5c,o+{- �a,,,•.a,�5on <br /> Phone (day): <br /> Address: �gll Fa,rV� � City: Lorg LG-�'',-Z ZIP:.S.S3,Sc(7 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: ��-e.i���� f2rno��Q,� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> F ax: 952-471-0682 <br /> �Window(s) ww�v.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) $ d'Op <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 informatio is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the r tion, the a lication ma not be issued. J <br /> ApplicanYs Signature: Date: s J �� ' ��, <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 �` <br /> �� ��i z ��� <br />