Laserfiche WebLink
City of Orono <br /> �uilding Perrnit �►ppiication for Maintenance / Repiacernent / Remodel <br /> �O� Mailing Address: permit number: �O��i'D D � (o <br /> PO Box 66 pC�c'`'� <br /> � Crystal Bay, MM362%+9086�-� Date received: ' — <br /> Street Address: .� 6 �U�� Received by: <br /> a �' 2750 Keue Pa�v��+ � j��Q , <br /> ��, � Y Plan review fee: <br /> tqkESHO��G Orono,MN 55356 � <br /> CITY OF ORONO Tota1 Fee: � �Z� �(0 <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.✓�� 2 ZZ// <br /> Incomplete appiications will be returned. (Please print) / �' <br /> GENERAL INFORMATION: n <br /> Job Site Address: � �'�+ �}-�t.��, 1=c� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes Na <br /> !f yes,a special event permit is required with Potice Department and City Council approval 60 days prior fo fhe evenf. Shuttle bus servi ce wi11 be <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events wil!not be allowed. <br /> CONTRACTOR/APPLICANT INFC?RMATION: <br /> Name: �/�c � /�j�'�� f��:,�/C�� <br /> State License# /3��39(o�L Expiration Date: j������ � <br /> Lead Certification Number: �,p�_ �ZUc��� ( Expiration Date: Z�cj/ ��/ 'j <br /> (for wo�k on homes that were constructed prior to 9978 —i��,�/��j <br /> Phone: (cell) ��/Z` ZUZ—�7�7 4� (office) �'I sZ- 24�1 �C��I�Z <br /> Mailing Address: � �j�-, '• . � �„J City:t i� �,��.°c.� ZIP: �'S ' , <br /> CantactPerson: �,�-v�,-f- ��.����� � Applicantis: ontrac / Homeowner (ClrcleOne) <br /> Email andlor Fax: ;-}�;�,��- (���/4C¢fj,,�r/�j,,�;j��� �it/j� �cc�-1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��n�'►.� "'" -�c�.�. l�.�c�v�'S <br /> Phone(day): �j S Z — Z/7 3 � �l�iS / <br /> Address: Gi iT� ICJc'S-f- � �r,r G /,� �� c�� CitY� J.S��!� ZIP:(���7-r-"c`'+�c` <br /> Email and/or Fax: —' <br /> PROJECT INFORMATION: Overall pro'ectdescription: j,r.► � rc�. <br /> Type of Project: Any earth m ement may afso require <br /> ❑ Door(s) [�Remodel ❑ Fire Damage MCWD review 8�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 /> ❑Window(s) www.minnehahacresk.orq <br /> Estimated Construction Valuation of Project(excluding {and) $ 7 5"� rx'�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 hisJher knowledge. The applicant recognizes that they a <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but <br /> reject it until it is complete; <br /> • Some or all of the information thaf you are asked to provide on this appfication is classified by State law as either pri�ate <br /> confidential. Private data is information which generally cannot be gi�en to the public but can be given to the subject of the dat <br /> � Confidential data is information which genera!(y cann t be given to either the public or the subject of the data. Our purpose ar <br /> intended use of this information is to annuaily u � our records and records of other governmental agencies required by law. <br /> ou refuse to su ! the in a on, th � li i ma not be issued. <br /> Applicant's Signature: f L�� Date: 2 � � " <br /> ��'�. �_ <br /> Owner's Signature: ' �� Date: ��Z�� �P <br /> l.ast Updated:Januarv 2015✓ /'J`-t„(/J .����1/`p <br /> �� �� � r� <br />