|
� � � City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: � Permit number: �
<br /> ��,�,�. PO Box 66 �
<br /> x\, � Crystal Bay, MN 55323-0066 Date received: '
<br /> � ��� ' Received by:
<br /> ',a ' �-�' �, Street Address:
<br /> � '�µ'- ti
<br /> � �� Gti 2750 Kelley Parkway Plan reviewfee:
<br /> r9kEs�4'� Orono, MN 55356
<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: r > n
<br /> Job Site Address: y �� �.�i'f� Sj���c' 1�;�,,,� Cl,.�,l�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or oth r Display Home? ❑ Yes �No
<br /> !f yes, a specia/event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficrent on-site parking is available. Non-permrtted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �Gt c� L,n�r,� U���i��Gis
<br /> State License # L g��S� Expiration Qate: u,� 3� �?�.j /
<br /> Lead Certification Number: -�_ 3c�3 5�� //- �( 3� Expiration Date: 3 - !�_ a�,��
<br /> (for work on homes that were consfructed prior to 1978
<br /> Phone: 3�v� ��'6-- 3c��''� (office) �SJ- 3 3� -'�a�� (cell)
<br /> Mailing Address: / � �� � p��i ��T �i.,,� City: ,,,}j ZIP: y S 3�j
<br /> Contact Person: �c,k�, L�,,�,,� Applicant is: ontractor Homeowner (CircleOne)
<br /> Email and/or Fax: �;,,,�lz�e �,-�g� �� , ,��,f-
<br /> PROPERTY OWNER INFORMATIO • 1
<br /> Name: � f-��� K
<br /> Phone(day): � �- Z�l�- g-� E 7 °
<br /> Address: /�/9SS /fJv,-fZi S ,r.� �r.-;v,� City: (�r-T,-iO ZIP: ,j 53��3
<br /> Email and/or Fax --
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review& ermits:
<br /> � Door(s) ) ❑ Remodel ❑ Fire Damage p
<br /> Re-roof, as halt Minnehaha Creek Watershed District(MCWD)
<br /> p ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar )� Deephaven, MN 55391
<br /> ❑ Restoration Water Damage Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ,g[Window(s)C�� www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ vOc�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the informafion 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 su I he 'nform 'o the a lication ma not be issued.
<br /> Applicant's Signature: � Date: �'�J �,�
<br /> Last Updated: 08-09-2011
<br />
|