|
_
<br />;. � �.
<br /> � ;: .:
<br /> ; �
<br /> City of Orono ��� ���� �� ���� ��
<br /> � ;'` y '�� ���
<br />�;�; . Building Permit Application for Maintenance / Renovation �� _ �-'�� �:
<br />� � . (windows, doors, siding, re-roof, etc.) {�
<br /> Mailing Address: ��j� _ �� f��
<br /> Permit number: �
<br /> �,� PO Box 66 �-�
<br /> /� Q Crystal Bay, MN 55323-0066 Date received: � � Z / �
<br /> i n��� �
<br /> ,_,FA Received b �,
<br /> � (•� � s, Street Address: Y�
<br /> �
<br /> Z,,,_
<br />�y�' �'�,n � �''�� �ti 2750 Kelley Parkway Plan review fee: '�
<br />�� �9kESH�g'� Orono, MN 55356 `^�;�
<br />� � � Total Fee: O� a� � s �
<br />� ` Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ��°��
<br /> �;.
<br /> This application form must be completed in full and all required information must be submitted. F;
<br />�` Incomplete applications will be returned. (Please print) i,�
<br /> ' GENERAL INFORMATION: �:
<br />�,r Job Site Address: ��'(p �j) �,�� ��,� x�
<br /> r�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �'No �l�
<br /> , �
<br />�; If yes, a special event permif is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be ��
<br /> �,' required unfess applicant demonstrates sufficienf on-site parking is available. Non-permitted events will not be allowed. �"
<br />,��< �
<br />�,�, CONTRACTOR/APPLICANT INF0,2MATION: /
<br /> �
<br /> �
<br /> Name: C� �G,�; ,L��G7`� d� °�
<br />��:, F�'a
<br /> State License# Ex ir �
<br />�� a�o,��� y �� p� ation Date: � r
<br /> '` Lead Certification Number. Expiration Date: ��
<br />�`� (for work on homes that were constructed prior to 1978 �
<br />� Phone: ) � /� - �/�j .- /�'1� (cell) �
<br /> �j, " _ �-�' /- 7a�-, (office
<br /> Mailing Address: � �� y �.� �� ,� � _ �.� �
<br />�; �i,� Cit : IP: .�- � �
<br /> r i' Contact Person: �j = C� ,��. ,, Applicant is: ontractor / Homeowner (Circle One) ��
<br /> r� ' Email and/or Fax: �L74 d�����o�s�,�G,�,��onJ- c� � �
<br />�� ;
<br />� �
<br />�- PROPERTY OWNER I�ORMATION:��`�e / //��C� ��
<br />�� Name: � �v
<br />�'� Phone (day): ��
<br /> �� Address: �� � .�r2 ,�� City: �j�� --- ZIP: �j�`�� � � ��
<br /> kry
<br /> Email and/or Fax ���
<br /> ��
<br /> ��
<br />�� PROJECT INFORMATION: �
<br /> "�.� Type of Project: Any earth movement may require �
<br />�' ❑ Door s MCWD review&permits: �
<br /> . O ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) a
<br />��' �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd =��
<br /> � ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �'
<br />�sR Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 y�
<br />���' ❑Window(s) www.minnehahacreek.orq �
<br /> �_�
<br />�' `� Overall Project Description: -;e � ���- ¢ ��.� � CS" ��
<br /> ; Estimated Construction Valuation of Project(excluding land) $ /��,a.-,
<br /> ��
<br /> q` .
<br /> , l �
<br /> �
<br /> a� APPLICANT ACKNOWLEDGEMENT: �
<br /> ��
<br /> • Agrees to provide all information required or requested by the Building Department; ��
<br /> ��
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they �
<br /> 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 /> 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 generally cannot be given to either the public or the subject of the data. Our ��
<br />` ` purpose and intended use of this information is to annually update our records and records of other governmental agencies �
<br /> re uired b law. If ou refuse to s I the informati , t a lication ma not be issued. '�4
<br />, ���;
<br />� . �:
<br /> Applicant's Signature: � , Date: j0�,7�/j/ �,
<br /> �
<br />� " �ast Updated: 08-09-2011 �
<br />�,-;, _..__ _ �
<br />
|