2015-01090 - adv plan review - Laserfiche WebLink

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' City of Orono • Building Permit Application for Maintenance / Replacement / Remodel {i.e. windows, dvors, siding, re-roof, etc. — NU STRUCTURAL EXPANSiON) Mailing Address: -s l �� PO Box 66 Permit number. p 0 S— oc..� Crystal Bay,MN 55323-0066 Date received: C�"' — S Street Address: Beceived by: �� ��, �� 2750 Kelley Parkway v-)� Plan review fee: ��• � G Orono,MN 55356 � � � �k�sx�� Total Fee: � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be mitted��w`� Incomplete applications will be returned. (P/ease print)� GENERAL INFORMATION: Job Site Address: �'�1� �11i1 ►� 5�{� � � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No !f yes,a special event permit is required with Potice Department and City Council approval 60 days pnor to the event. Shuttle bus s ic will be required un/ess app/icant demonstrates s�cienl on-site parking is available. Non-permitted events will not be aUowed. CONTRACTOR/APPLICANT INFORMATION: Name: S�n��„� (�U;i��ers LLC State License# �L 6�"�( �6 g Expiration Date: �3 j3�b Lead Certification Number: NAT � 1 b b �o t7�-� � I Expiration Date: }3 �,� � � � ! {for work on homes that were constructed prior to 1978 Phone: (cell) �o�Z- ��j — � �,1 $ (office) �l� -�� - � o Mailing Address: � �, � City: (�p� S ZIP: S'�v\ Contact Person: � Applicant is: Contrac r / Homeowner (Circle One) : Email and/or Fax: � � _ � ` PROPERTY OWNER INFORMATION: Name: (��-� L c�� c�N � Phone(day): �}�Z_ ] 2� � '�`' Address: ""� Z Z �,�h r City: w�, � ZIP: � Email and/or Fax: .N, �. � � ' PROJECT INFORMATION: Overall ro�ect descri tion: I� +�' ce, (�ut�„ r t- i 'uI' �j`��j� ` Type of Project: Any earth movement may also require �/ MCWD review& ermits: ' ❑ Door(s) ❑ Remodel 1�4Fire Damage p T Minnehaha Creek Watershed District MCWD e-roof,asphalt �epair ❑Storm Damage � � ❑ Re-roof,cedar 18202 Minne#onka Blvd ❑ Restoration ❑Water Damage Deephaven,MN 55391 Phone: 952-471-0590 ❑ Re-roof,other(specify) �Siding ❑Other. (specify) Fax: 952-471-0682 ' Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ � ,�e„�, �OK f'r•�c APPLICANT ACKNOWLEDGEMENT: • Agrees to provide a�l information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or ' confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. ' Confidential data is information which generally cannot be given to either fhe public or the subject of the data. Our purpose and ' intended use of this information is to annually update our records and records of other governmental agencies required by law. If ou refuse to su I the info tion the a li ation ma not be issued. q Applicant's Signature: Date: L� l�� Owner's Signature: �� —"��'�'� Date: �I� I I j Last Updated:January 2015