2016-00926 - addition remodel - Laserfiche WebLink

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. City of Orono Building Permit Application for Maintenance/Replacement/ Remodel —Residential ONLY � (i.e.windows, doors, siding, re-roof,etc.—NO STRUCTURAL EXPANSION) O MailingAddress: Permitnumber: CJ(/ � PO Box 66 � � Crystal Bay,MN 55323-0066 Date received: ��'� � Str t Az78ress: �7� ?� � 50 Kelley Parkway•Lu��'��o � eview fee: `�. . S� L �q'�'6srio��" Oro� , ,- Total Fee: Main: 952-249�600 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 appiications will be returned. (Please print) GENERAL INFORMATION: / + , ��/ Job Site Address: �b� /�/o✓'� !�"� 04 �✓�J✓10 �� Will this be a Parade of Homes,Remodelers Showcase Home or other Display HomeT ❑Yes No lf yes,a specia(event permit is required wifh Police Department and City Council approva160 days pnor to the event. Shuttle bus service i!1 be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: �d'Ge�'fe� '�- �Soc�ot'�G�S State License# \ G pp � ';$O Expiration Date: b'�j. '�� . 2p�$j Lead Certifica;ion Number: �Pr`— 9�'�y�- Z Expiration Date: p(�, OQ'. 7 u Z,.� (for work on homes that were constructed prior to 1978 Phone: (cell) (o�Z„ Z� , ��'7 (office) q5 Z, y 5 . 9yy t Mailing Address: �g��Z ; �� City: (N y ZIP: 1 � Contact Person: L Applicant is: Contractor / Homeowner �ci��i.o�,.� Email andlor Fax: 'w,1 •�� S-}y�,L-�,f (np,/y CL, C.ov�n PROPERTY OWNER INFORMATION: �1 � _ Name: ��b�v�e��}'e� �LC.V1ac.l�Y'S Phone(day): °.5�2•�r� �_ $e��, n Address: �(o�1 ti�I'1'�. �v+Y�•r+ �Zo.,eX- City: Q✓'e H o ZIP: �j S �S �e Email and/or Fax: Gt�n+-o :✓�c�i-�c, F� ✓�'�c.. Gow. PROJECT INFORMATION: Overall project description: � � ��LS� I �.� � ' Type of Project: Any eaRh movement may also require �Door(s) �Remodel ❑Fire Damage MCWD review 8 permits: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnelonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952�71-0590 Fax: 952-471-0682 �Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ � 1 S'�t7 a� 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 altemative but to reject it until it is complete; • Some or all of the informatio� that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generaily 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 the public or the subject of the data. Our purpose and intended use of this information is to annually u te our records and records of other governmental agencies required by law. If ou refuse to su I the i tio ,the .'li ation ma not be issued. ApplicanYs Signature: Date: $•� • � � Owner's Signa re�/ Date: Last Updated:January 2016