Laserfiche WebLink
� City of Orono <br /> � Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O� Mailing Address: Permit number: p7d/ —(� � (o <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-00 6 �/'n Date received: 1—� <br /> ���,. <br /> � � Street Address: �$ Received by: m <br /> ti�, G� 2750 Kelley Parkway� � Plan review fee: <br /> �q �, Orono, MN 55356 ��� /� <br /> kEs H ot� <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 returne . (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � G.��.� �• ��� <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 requi�ed 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/AP�LICAI�T INFORMATION: -J � <br /> Name: j ���� iG��7 �c��!'1�-r��I�(/1 CT� �??�"L <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) ' r Z— ' �� � �Z (office) <br /> Mailing Address: Z� �, ��� r��. City: � ZIP: <br /> �s� -� � 5 � S <br /> Contact Person: �� (,� Applicant is: Contract r / Homeowner (Circle One) <br /> Email and/or Fax: � � '� �'r.+..� <br /> ..0✓1 �i�.r S i C ro c � �,q,�n.c�� <br /> PROPERTY OWNER INFOR ATION: � o ., <br /> Name: � �7 YG �� � �/�i�Y� i <br /> Phone (day): Z — �- � ��-- �� � <br /> Address: Z�2 � l,�r.v� 1 ��, i�� , S � City:�y���,�f���ZIP: �-�j��l � <br /> Email and/or Fax: �-�^ ` `�� �� ��, r <br /> ,� z, <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review& permits: <br /> �.Re-roof,as halt Re air Minnehaha Creek Watershed District MCWD <br /> p �. p ❑ Storm Damage 15320 Minnetonka Blvd ( ) <br /> ❑ Re-roof,cedar ❑ Restoration �Water Damage Minnetonka, MN 55345 <br /> 0 Re-roof,other(specify) �(J 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) $ G��J,--- <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 cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the info ation, a licatiom m �ot be issued. <br /> ApplicanYs Signature: > - , Date: � /7 � /� �� <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />