Laserfiche WebLink
,� N <br /> ' City of Orono � <br /> Building Permit Application for Maintenance / Replacement / Renovation � <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc. �j <br /> / Mailing Address: ��� <br /> ��NO PO Box 66 PeRnit number: <br /> Crystal Bay, MN 55323-0066, �� ,f/ Date received: <br /> `, ���. ��,� — <br /> ^ , � � Street Address: �,;U � Received by: <br /> : � 2750 Kelley Parkway p�(1�' �' plan review fee: <br /> f � Orono, MN 55356 ��� <br /> `qkfSHOQ'� // .�S <br /> Total Fee: �,v <br /> Main: 952-249-4600 Fax: 952-249-4616 ww�v 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: n �.�- c <br /> Job Site Address: ��-(`i5 ��1 i��'J �,N �!-'��f jM I\ ��3..}� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a special event permit is required with Police Department and City Council approva!60 days prior to the event. Shuttle bus servi wil!be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be al/owed. <br /> CONTRACTOR!APPLICANT INFORMATION: <br /> Name: <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) (o�ce) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner �c�rue o�e> <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMAT�N: <br /> Name: `f�+,U � 1J J�C 1`�=�' <br /> Phone (day): � � � <br /> Address: V� V,� ,,/� City: ��fJ� ZIP: ��.���j <br /> Email and/or Fax: '' <br /> ► ��"11 �,�5r�1. �' L <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 ❑Repair ❑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(speciiy) ❑Siding �Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 • <br /> ❑Window(s) �� li �r' DCj��–POC�-� www.minnehahacreek.orq <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 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 canno be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to ann pda o records and records of other governmental agencies required by law. If <br /> ou refuse to su I t info a , h li ti m not issued. <br /> � � <br /> ApplicanYs Signature: -� Date: " i � � <br /> Owner's Signature: Date: <br /> Last Updated:03/O6/2013 <br />