Laserfiche WebLink
1 �\ � e��'�� <br /> �- � � � �� � s <br /> `� �3g <br /> - �- � ' Ci of Orono <br /> tY <br /> Building Permit Application for Maintenance / Renova i <br /> (windows, doors, siding, re-roof, etc.) <br /> ---� Mailing Address: Permit number: ��L' � r �- C i� l�- <br /> ` PO Box 66 <br /> ������V Crystal Bay, MN����-096f��-- -Bate-r.�ceived: I C -- 7—�( <br /> '�� ���' � ��d l�lrc- /t r cl���ys'� _ _ , <br /> ' ��� I � - L I Z � -� Received by' ----- 1� <br /> ,� t� � / Street Address: <br /> �'S'.F, ,� y G. 2750 Kelle Parkw > 2 L' S/ � �'� <br /> Y Y �ariew ee:--- <br /> r9kE3Ii04'� Orono, MN 55356 - ----- -- <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. (P/ease print) <br /> GENERAL INFORMATION: / �� � ��/ <br /> Job Site Address: I, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a specral event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service wilf be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI A T NFORMATION: � <br /> Name: � � � <br /> State License# S Expiration Date: -/Q <br /> Lead Certification Number: _- - Expiration Date: �-a�-/� <br /> (for work on homes fhat were cons ructed prior to 1978 / // <br /> Phone: - - � office) �p�� ' ��6 '�7� �� (cell) <br /> Mailing Address: �¢ , City: ,�� ZIP:�� , <br /> Contact Person: � G Ap licant is: Contractor / Homeowner �c���ie o�e� <br /> Email and/or Fax: �p <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��������� <br /> Phone (day): ySa- � - C((� <br /> Address: ���� � City: ��10 ZIP: <br /> Email and/or Fax �������„ (� ����� <br /> �y-�� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) �,Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> P hone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overall Project Description: , � <br /> Estimated Construction Valuation of Pr �ect(excluding land) $ o O <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I e formation, the a lication ma not be issued. <br /> Applicant's Signature: Date: �����/ <br /> Last Updated: 08-09-2011 /' <br /> ��i�t 1'vov- (.i,�-ty/ t$CD��O�tJ� <br />