Laserfiche WebLink
From: 05/23/20�7 �4:43 #267 P.002/003 <br /> City of �rono <br /> Buifding Permit Appiication for Maintenance/Repfacement/ Remodel—Residential ONLY <br /> (�.e. vv�r�ciow�, dcz�rs, �id��g, r�-��c��, e�c. � I�O �TRUGTUE��. EXPA�[S[CC��4� <br /> �O� Mailing Address: permit number: ��7' �5j0� <br /> O PO Box 66 <br /> Crysta�Bay,MN 55323-OQ66 Date received: S�-�7 <br /> � � <br /> StreetAddress: Received by: <br /> s�, `� 2750 Keiley Parkway Plan review fee: <br /> � Orono,MN 55356 �// � � ^ <br /> "�KFSHoa�` Uj <br /> Total Fee: <br /> Main: 952-249�l600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be comp(eted in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: ,� 3� � �C� � <br /> Job Site Address: �' �, �"r�'-2.-�� <br /> Will this be a Parade of Homes,Remodeiers Showcase Home or other Display Home? Yes �No <br /> If yes,a special event permit is require�l with Police Department and City Counal approval fi0 days p�ior to the event. Shuttle bus service will be <br /> r�squired unless applicant demonstrates suHScient on-ske parking 1s availabk. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLlCANT INFOR ATfON: . <br /> Name: y�S ' <br /> State License# G�p� �� ?� Expiration Date: "3 ( <br /> Lead Certification Number: ��-j-�..F,��2,g cs� ... � Expiration Date: � �� <br /> (fo�work on homes that were constructed prior to 1978 <br /> Phone: (cell) 9'�2-3 00-�(p � � (office) '"� b�-��j C� _-'g 7 8 p <br /> Mailing Address: -�j I�� ����s-�,-�� c.!- p City. ��(��� ZIP: � 3-��C'�' <br /> Contact Person: a,,ti,� ��� Appiicant i � -�__n ac / Homeowner �cuea o�eT <br /> Email and/or Fax: (,t (, <br /> PROPERTY OWNER INFORMATION: <br /> Name: �C�Ir1�w.r,u!-.oti, 0�,�'',�c.,1 <br /> Phone{day}; �—'' <br /> Address: C�y; Z�p: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall roject description: <br /> Type of Project: Any eaRh movement may slso require <br /> ❑Door{s) ❑Remodel ❑Fire Damage <br /> MCWD review 8,perntits: <br /> Re-roof,asphaR ❑Repair ❑Storm Damage Minnehaha Cr�eek Watershed DisUict{MCWD) <br /> ❑Re-roof,cedar 15320 Minnetonka Blvd <br /> ❑Restoration ❑Water Damage Minnetonka,MN 55345 <br /> ❑Re-roof,other(apeciiy) ❑Siding ❑Other:(specify) Phone: 852-d7'1-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(exciuding land) S . CT2� <br /> APPLICAN7 ACKNOWLEDGEMENT: <br /> • Agrees to provide all informabon required or requested by the Buitding 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 applicafion baing aware that upon failure to do so, the staff has no altemative but to <br /> reject it untit it is complete; <br /> • Some or all of the inforrnation 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 ti�e subject of the data. <br /> Confidential data is information ich generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this informatio s to annual ate our records and cords of ather govemmental agencies required by law. If <br /> ou refuse to su I the'n tio i on e iss d <br /> ApplicanYs Signature: Date: Z 3 � � <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />