|
�
<br /> City of Orono
<br /> , � Building Permit Application for Maintenance / Renovation
<br /> . (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address:
<br /> j��\ PO Box 66 Permit number:
<br /> �� �� O�, Crystal Bay, MN 55323-0066 Date received:
<br /> � gy ,
<br /> I 4 ' Received by:
<br /> ,� � � ,<;,J__ �, ; StreetAddress:
<br /> �.�,t � ' ,'"� �ti � 2750 Kelley Parkway Plan review fee:
<br /> 9�ESH0�`� 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. (Please print)
<br /> GENERAL INFORMATION: , , , �
<br /> Job Site Address: ���U � �in�• � �� � �'r �`'z-
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o
<br /> If yes, a specia/event permit is required with Police Department and City Counci/approva/60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitfed evenfs will not be allowed.
<br /> CONTRACTOR!APPLICANT INFORMATION:
<br /> i
<br /> Name: s�,�yz-�" �� ��'�rta-��i�n �-��wp L.�C_ .
<br /> State License# ��3 75(�G��j Expiration Date: ,�-�/ - i 3
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were consfructed prior to 1978
<br /> Phone: �� �7_ s y�- //(�C� (office) /,� �,�-�j % - // � `� (cell}
<br /> Mailing Address: S �� �,,� SSSu� �c. S�J City:�yj,��� „ ZIP: s���--�
<br /> Contact Person: �/��.�. ��� Applicant is: ontrac�or Homeowner (Circle One)
<br /> Email and/or Fax: I�'1v2�r-�c=� �Z .Scr�n;-�--�•�, _ �.��-,-z
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �L'Lv�. �S�G� �.1-��
<br /> Phone (day): 9i3 -1G7� -�Si3
<br /> Address: /��,�, �,.{.,.,a� C',_ct� � �,,.�„ City: �r`D►'?fj ZIP: -�5,� ��
<br /> Email and/or Fax
<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 /> Phone: 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: ^Pr���ntc_ ,5•���c.c� ;n .�� y,'c;s�v� ctir� ,n�n.1R � ,T ; ,�e_s� �a.c��
<br /> Estimated Construction Valuation of Project (excluding land) $ ��.x>. "�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the informafion 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 applicafion 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 the i ormation,t a ficafion ma not be issued.
<br /> O �. � � _.
<br /> ApplicanYs Signature: _ Date: / ��
<br /> �ast Updated: 08-09-2011
<br />
|