Laserfiche WebLink
Q -z�- l3 <br /> ' , City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> "J ^", Mailing Address: 9 � <br /> � /��,VO�,, PO Box 66 Permit number. o?D .r �D g <br /> Crystal Bay, MN 55323-0066 Date received: 4��'�,� <br /> ( <br /> �� , ' a � Street Address: Received by: <br /> \'. � � 2750 Kelley Parkway PI <br /> �Fl,q �� Orono, MN 55356 �� , <br /> �� k�sNo� <br /> �----.-- Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www ci c;rc�no r7;n us ��� �..� 1SSZI-? �s <br /> This application form must be completed in full and all required information must be submitted. � <br /> Incomplete applications will be returned. (Please print) �a 3�3� <br /> GENERAL INFORMATION: � <br /> Job Site Address: _ � Cg�O j�,CO�N Sf"�D� ��(.�[r <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes �No <br /> If yes,a special event permrt is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus servi e will be <br /> required unless applicant demonstrates sufiicient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �'�c� Co��rnv LTZo%( <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were constructed prior to 1978 <br /> Phone: (cell) (office) �(P 3. tt�g, �jg�� <br /> MailingAddress: 3'3�jo � p City: Cp� ZIP: G'j-r'j3-r'j'7 <br /> Contact Person: (3�,�� �� Applicant is: r / Homeowner (Circle One) <br /> � Email and/or Fax: 6Kp_v�n�(� P.b�R'f�C�vlS i. �o✓V1 <br /> � PROPERTY OWNER INFORMATION: <br /> Name: TkR-t� IZ-��L�-S �I� I�lS7�l�'i� <br /> Phone (day): 7/p3• �'j�. (o`I l�' <br /> Address: ��00� XErll V W1 L/kNC I�,O�T�f City: PLy l�'tp�7TY� ZIP: 'J��j��� <br /> Email and/or Fax: ��3, �'j�f, 3Z 87 <br /> PROJECTINFORMATION: Overall ro�ectdescri tion: ST�GTJIt�L yc�i}-I�� TD��`�— (ZE�P�iiLS <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt �Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) rn�ww minnehahacreek orq <br /> Estimated Construction Valuation of Project(excluding land) $ 75, aoo <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 are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> 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 data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: �jL�l-1/� /�`'� Date: �—��"'�3 <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />