|
,� � ..
<br />�, . , �� � �:� :�� �
<br /> � � ��
<br /> City of Orono � �� �� ��'�� '� �
<br /> ��:
<br /> � ' r Building Permit Application for Maintenance / Renovation '
<br /> _ ,T
<br /> s2�`i„'
<br /> �' (windows, doors, siding, re-roof, etc.) F�
<br />�; �;�;
<br /> , Mailing Address: aG��_ � -7� '��
<br /> 4 �.,0,� PO Box 66 Permit number: / �
<br />�Y'
<br /> F, � Q Crystal Bay, MN 55323-0066 Date received: �j � ��
<br /> �� 3 v�9
<br /> a � `" �, � Street Address: Received by: �
<br /> �' �_,;,.
<br /> �'� � ,w;�, G� 2750 Kelley Parkway Plan review fee:
<br /> L�kESH�� Orono, MN 55356 (jf�
<br /> Total Fee: � / 9���
<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: "� `�S /�IYI�I� �l/� _ - � �,�J �� �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No �i.a
<br /> If yes, a special event permif is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus s rvice will be
<br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �
<br /> CONTRACTOR/APPLICANT INF�RMATION: 7
<br /> Name: C�� 1� ,���� S �T�tJ I� ��P�� /1 /�,�-,����n,�'-`
<br /> State License# Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes thaf were constructed prior to 9978
<br /> Phone: � Z S� ��� � (office) S S �� �� (cell)
<br /> Mailing Address: p � � �3 City: �o.,,;� ZIP: SS `
<br /> Contact Person: Applicant is: Contractor / Homeowner (Cirde One) �
<br /> Email and/or Fax: `�
<br /> PROPERTY OWNER INFORMATION: %
<br /> Name: �-f-� ����1'� l`�v�'y!� S � Vg'ri?�S l�i'�} U/� �����tJ� � �
<br /> Phone da c i �
<br /> ( v)� J s� I S�� 7/0 l
<br />�4 Address: ,� �S3 S� ��o,E L�'�C� /�l CitY: C���,� � ZIP: � S � �'Z� y
<br /> Email and/or Fax �
<br />�X y�
<br />�"' PROJECT INFORMATION: k�
<br /> '` Type of Project:
<br /> �
<br />� , Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel Fire Damage MCWD review&permits: �
<br />�., Minnehaha Creek Watershed District(MCWD) �
<br /> � ❑ Re-roof, asphalt ❑ Repair Storm Damage 18202 Minnetonka Blvd `�
<br />�`� ❑ Re-roof, cedar Dee haven, MN 55391
<br />� " ❑ Restoration ❑Water Damage p �
<br />� = Phone: 952-471-0590 �
<br />� � ❑ Re-roof,other(specify) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 ��
<br />��� �
<br />+ '` ❑ Window(s) www.minnehahacreek.orq
<br />�,� Overall Project Description: � � f� ��' � ; �, ,. �
<br /> . 1�'I u� � ✓1 � ✓-1� 1 c>�
<br />. ; ��
<br /> t Estimated Construction Valuation of Project(excluding land) $ y� S � a�
<br />� �
<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 �
<br /> n are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative ���
<br />�,�. but to reject it until it is complete; ^�
<br />��, �
<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 �
<br /> data. Confidential data is information which enerall cannot be "
<br /> r 9 y given to either the public or the subject of the data. Our
<br />� purpose and intended use of this information is to annuall date our records and records of other governmental agencies �
<br /> re uired b law. If ou refus to su I the information, he lication ma not be issued. �
<br />� / ��
<br />�' ApplicanYs Signature: � Date: � 3/ �o� �`�
<br />�
<br />�,i Last Updated: 08-09-2011
<br /> ,
<br /> ;
<br />�� . a��
<br /> , 4
<br />
|