Laserfiche WebLink
� . �ga , �-� <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> . �. ;� . .:� .�,_ . . <br /> � _ <br /> :.� �s'i.a 4..��.';.st,L ,.:�..e •e � ` -_-, : - . _. � . �. _ �. �. - _ . � <br /> . . _�.... . �.� ..__. � <br /> O Mailing Address: lr` 7 Permit number: ``' — <br /> � �TO PO Box 66 L� ��\ 1 __ <br /> Crystal Bay, MN 55323-0066 Date received: <br /> � � Street Address: �� e�� <br /> ti� � 2750 Kelley Parkw y� L � r,-1 Plan review fee: 9C�� • <br /> t � Orono, MN 55356 Z�< < <br /> �KfSH��� Total Fee: <br /> Main: 952-249�600 Fax: 952-249-4616 ��:�r u= <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: , ,� l <br /> Job Site Address: ����' °V '7�1���G �'�C ��v�� V� <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. Shutt/e bus service will be <br /> required unless applicant demonstrates sufiicient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFOR�ATION: _, <br /> Name: r� ��'�� c� v����-t.h -,���i ��C�r-S <br /> State License# L �' "�3 ' Expiration Date: .3 --�) —) �� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) �� "�>) - �`� � <br /> Mailing Address: � �j'� ,�;, ,�� ,��� City: '' : ZIP: � '� � <br /> Contact Person: ' Applicant is�__Contractor:�/ Homeowner (Circle One) <br /> Email and/or Fax: � ��-,r� � �✓ :j� t-�,��� <br /> PROPERTY OWNER INFORMATION: � �,�c ` A 1�'� <br /> Name: ; r:, . ;;1,� , V� <br /> Phone(day): � — � Q " � 2.� n <br /> Address: ��) `~j U�-�'h S��(. /�,�, ✓�P City: �����,,�yil ZIP: �S �J(-�� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro�ect description: <br /> Type of Project: � Any earth movement may also require <br /> ��'�'��'��►"'� MCWD review&permits: <br /> ❑ Door(s) �.Remodel ❑ Fire Damage <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) ^;�rr�v.m�nnenahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ ? 7� <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: '� Date: 63� � �/5 <br /> � � 1 � <br /> Owner's Signature: �Ll 1-,! �,�(i�i ,�(�(:�Y'1 Date: ;l�(i��/`) <br /> Last Updated:January 2015 <br />