Laserfiche WebLink
City of Orono <br /> Bui�ding Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> �O . ` Mailing Address: Permit number: �� ,j.. �d9 <br /> lYO PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: � �� � <br /> Street Address: Received by: <br /> y G� 2750 Kelley Parkway Plan review fee:� <br /> `� Orono, MN 55356 <br /> lqkesxo�`� �la�v• S� <br /> Total Fee: <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: ?j12a N. �c�t.E �-. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes [�No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: — ,�r,�sE <br /> State License# L 4 g g Expiration Date: �-j <br /> Lead Certification Number: v.� U, Expiration Date: <br /> (for work on homes fhat were construcfed pr' r to 1978 <br /> Phone: (cell) �1z • y�g. gg 5� (office) M�,,���-���.a <br /> Mailing Address: 2 p �oQ ��,v b City: � ZIP: �'j5 3 <br /> Contact Person: �Q� ���SM �� Applicant is: � ract / Homeowner (Circle One) <br /> Email and/or Fax: �ar\ � -�ti�2�,,��SR_ • G.c�v.�, <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��K �jz� <br /> Phone (day): Cp�2 g 12. CjOt,/S- <br /> Address: ���7 � �(, 5�� D�_ c�ty: a,�,�/p ZIP: <br /> Email and/or Fax: �jZ, bc,,•-h � r�'ba Go►� 5�. ! -f-� �►a - �o ,rti <br /> PROJECT INFORMATION: Overall project description: <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 /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ l05� Obb <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 infor i n,the a lication ma not be issued. <br /> Applicant's Signature: �`�" Date: �� 12 � I�' <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />