Laserfiche WebLink
, City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> ;i � • �:��a-�� .��;r�. sE: : , ��-����. �tc. _ !��1 5����l��'U�r` :•�i <br /> �O • O MailingAddress: Q/7—OD��S <br /> ��% PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-OOf ,/� Qate received: �- ��� <br /> I 1 / <br /> Street Address: r (J,,V / Received by: <br /> y� � 2750 Kelley Parkway ���� /� Plan review fee: <br /> L Orono, MN 55356 � — <br /> C�'�ESH�R� ��/ / r v <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: 1��5� � f2Vf1�-� (s9'r7�(-�c- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> lf yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus servrce wiN be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permiKed events will not be allowed. <br /> CONTRACTOR/APPLICANT INFOR ATION: <br /> Name: � �,��� ,� ti <br /> State License# 31"j�6� Expiration Date: x���) I"7 <br /> Lead Certification Number: ,v f,4.. Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) "'j 6� �"g �Q �' (office) <br /> Mailing Address: g(p � � City: ' T7�-ZIP: 5� 3"Z� <br /> Contact Person: '�� Applicant is: rac n / Homeowner �c���ie o�� <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: ���� <br /> Name: /'�2�J�[ 1F �y�t <br /> Phone{day): �f Z - �c.��- j Z'�� <br /> Address: ��s" �7/L✓'��,w ��Cy�.� � L-�+"`t, City:��Q _ ZIP: s��,�/ <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: ��'4� �L'� ���'}� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �temodel ❑ Fire Damage MCWD review 8�permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑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 /> ❑WIIIC�OW�S� :i^v';'i�J.f";l(iln�'hahr�CiEEk;.crq <br /> Estimated Construction Valuation of Project(excluding land) $_Z�f?-c7 <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 altemative but to <br /> reject it untii 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 ca�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 annuaUy update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the i orm 'on,the a lication ma not be issued. <br /> Applicant's Signature: __,._ Date: Z�Z � �� <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />