2011-00207 - roofing - Laserfiche WebLink

Home Browse Search

. .Y4� .� . ��,: )..�;� t' >; R ,� F �ve , � � City of Orono ��'� � ; :_ � � � . � , � Building Permit Application for Internal Work � (windows, doors, siding, re-roof, etc.) �� Mailing Address: Permit number: �U//—d�� 4v�,� PO Box 66 � � �� Crystal Bay, MN 55323-0066 Date received: / °� a t�'' ��;:�,� s, Street Address: Received by: � '��° �' ��"� ��' 2750 Kelley Parkway � Plan review fee: � � � r�kESH04'� Orono, MN 55356 k'� � Total Fee: �9�� 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 submitted. � ' Incomplete applications will be returned. (Please print) � GENERAL INFORMATION: ' Job Site Address: �l� -�f � � , � ,��;�' " � „ Will this be a Parade of Homes, Remodelers Showca Home or other Display Home? ❑ Yes No � /f es, a s ecial event ermit is re uired with Police De artment and Cit Council a `� , Y P P 4 p y pproval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. � �30: CONTRACTOR/APPLICANT I F RMyA/--TION:> �' �, Name: � .y�// g., Ji L ) :�; State License# ��-� ��; Expiration Date: � /�h E,4 Lead Certification Number. Expiration Date: �=` (for work on homes that were constructed prior to 1978 E ., �`, Phone: _ j � -�,' � (office) (cell) �� Mailing Address: -- Cit : �` ' � � " �., Y �� ,r'��' ZIP: �":�� ; � Contact Person: Applicant is: C6ntr_ acfo��/ Homeowner (Circle One) p� Email and/or Fax: �.� ° �� PROPERTY OWNER INFOR ATION: � � I ' Name: _,�!'� �ac� 'C �� �, Phone (day): �"�� 2 '�d� '" Address: ��y�> � �� City: ZIP: �� .�; � Email and/or Fax r_� �`. PROJECT INFORMATION: -� �.� Type of Project: Any earth movement may require � MCWD review& ermits: �` ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watersh d District(MCWD) � ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �d ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 �' Phone: 952-471-0590 �� �Re-roof ❑ Fire Damage Fax: 952-471-0682 }� �� - www.minnehahacreek.orq g�� Overall Project Description: : -.,,. - �,, _ �� y,�� ��: Estimated Construction Valuation of Project(excluding land) $�' �� .� APPLICANT ACKNOWLEDGEMENT: } • Agrees to provide all 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 z� data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our � i4 purpose and intended use of this information is to annually update our records and records of other govemmental agencies � re uired b law. If ou refuse to su I the information,the a lication ma not be issued. `� ' /�---�` , �: ApplicanYs Signature: � U , -- - Date: "L/'�� �� Last Updated: 03-01-2011 ,:� � ��;, w�