2017-00475 - water damage/sewer loss repairs

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� City of Orono Building Permit Application for Maintenance i Replacement/ Remodet — Residentia! ONLY �±.t. wyv:��^,,a. r$ . _ ,... ..wc�;,. , . 3 . .,. . ��_.' ..� .�ti°!�'."��.i�>,��. �=°r�°.�';�aF��J°ti} ' �j ` Mailrng Address: Permit number. � "� W�� ; �� A PO Box 66 � �/ � Crystal Bay, MN 55323-0066 Date received: C; "� � � SfreetAddress: Received by: „��_�� y j '1� �` � ,,, , _ 2750 Keiley Parkway Plan review fee: �• - � `��! � "f Orono, MN 55356 � 1��`�' ��'�k'�SNp1�,� ---- � Total Fee: t � � Lt l , ��. Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us f This application form must be campleted in full and all required information must be submitted. L;v�.Scf ��'Z�!� Incomplete applications will be returned. (P/ease print) GENERAL INFORMATION: � + � , Job Site Address: i��-��'�.�' �V!��'�"fl �)�1t,,� k,/�!�- �;��V��!'�� -�`� "74�� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No !f yes,a specia!event permit is required with Potice Department and Crty Council approva!60 days pnor to the event. Shuttfe b�s service will be required uMess applicant demonstrates suffrcient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APP�ICANT INFORMATION: Name: � t-t_.� ` � ��r'�..!�t�..��' I . State�icense# � '��-�� Expiration Date: ; g' Lead Certification Number: _ �� •, �� Expiration Date: L� }'� (for work on homes fhat were consfructed prioi to 1978 Phone: (cellJ (office) , � j4 - '� �_ � 5� Mailin Address� (C;�� ,J��vi; - 9 f� `�". ii/ .i� City�"�� Yc��' ZIP: c�5�.��3C.% Contact Person: �7�-,��,�� ,�_��-.� Applicant is: Contractor �(, Homeowner (CircfeOne) Email and/or Fax: + ��,��- ��Ci.r1i Sc`.h C�.. �u/l.i-x1, �'>r�� .�� ('�'�;r� _ ` PROPERTY OWNEf,�INFORMATION: Name: �, �.�'�_t`x'.r'1 Phone(day): � j:�_-' �� 7 7 � Address: `3�kJ�' �7'r'�-�i`il'lrt�� (�iv� City: � 7y-�7i� " ZIP: `j�5 �`�� Email and/or Fax: PROJECT INFORMATION: Overall project description: � �F � `r"' �' � _," (`��"` — �. ' � ' Type of Project: Any earth movement may also require ❑ Doar(s) ❑ Remodel ❑ Fire Damage MCWb review&permits: Re-roof,as halt Re air Minnehaha Creek Watershed District(MCWD) ❑ p � p ❑Storm Damage 15320 Minnetonka Blvd ❑Re-roof, cedar ❑ Restoration �f Water Damage Minnetonka, MN 55345 ❑ Re-roof,other(specify) ❑ Siding �]Other. (specify) Phone: 952-471-0590 � Fax: 952-471-0682 ❑Window(s) ��,;� � �+' 'J�-1.��1z�;;�r• www mir7nehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ �L � 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 information that you are asked to provide on this application is classified by State law as either private or I confidential. Private data is information which generally 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 update our records and records of other governmental agencies required by law. If ou refuse to su I the�nformation,the a li tion ma not be issued. ApplicanYs Signature: � �� 7 ' �',�1,�`,�-�r4� Date: �� / , �� / � Owner's Signature: � Date: .��'/ Q"" (� � � Last Updated January 201