Laserfiche WebLink
� '� City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O Mailing Address: Permit number: c�?�/ -C_:/ � <br /> PO Box 66 <br /> � 0 Crystal Bay, MN 55323-0066 Date received: �� -Gw�"� <br /> Street Address: Received by: ��'�i" <br /> y � 2750 Kelley Parkway Plan review fee: —' <br /> F �' Orono, MN 55356 <br /> `�kESN�R� <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: J Q� �( i -r-G C,R , � �k�� <br /> Will this be a Parade of Homes, Remodelers Sho ase ome or other Display Home? �Yes ❑ No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: � -Z� � �� i � �,� � <br /> State License# � Q aj Expiration Date: � �� <br /> Lead Certification Number: ��,(�7, �p��� _ � Expiration Date: � � <br /> (for work on homes that were constructed prior to 1978 ' <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �-��v-� � -, y�.l� � <br /> Phone(day): (��j�� �J� C� - g'�9 <br /> Address: '-{-� City: ZIP: � <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: /r--_; ^-� Any earth movement may also require <br /> ❑ Door(s) � �(Remodel ❑ Fire Damage MCWD review 8�permits: <br /> ---- - - - " Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt � F2epair ❑ Storm Damage <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ "� f , � �-`� <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 dat� <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose � <br /> intended use of this information is to annually update our records and records of other governmental agencies required by la• <br /> ou refuse to su I the information, the a lication ma not be issued. <br /> ApplicanYs Signature: � Date: / / <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />