Laserfiche WebLink
City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel —Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> pT Mailing Address: ,.-^�) <br /> .0.Y PO Box 66 Permit number: f/J� ,/ <br /> Crystal Bay, MN 55323-0066 Date received: ,.;�, // _ <br /> Street Address: Received by: �-(� 0//`3 7 <br /> y 2750 Kelley Parkway Plan review fee: <br /> `� Orono, MN 55356 _ <br /> �1kssHOV` Total Fee: Z tl 0.- <br /> i g,�f <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 0" <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: 3,-(1t. E. L--- C4 - <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes El 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/APPLICANT INFO�ON: <br /> Name: t.c,. ,--1,.-.. L _Lvvt.11 WIZ✓r\ac. - <br /> State License# ('k..0"/ 001-7 Expiration Date: 3[3(l/5 <br /> Lead Certification Number: &J A't L-/(o.'/3— -. Expiration Date: /Lf /')--a <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) SCc e- i S off--///-- (office) <br /> Mailing Address: ( p ..I 7 FL or, cf?ck, (rear.(-v-ea ai City: Cw._s„f"ko (, LZIP: 3,)..7 37). <br /> Contact Person: SLo4i- .bcwKhn.a 4-, Applican[is: ontra / Homeowner (Circle One) <br /> Email and/or Fax: SCS+-etc, "Is4,1m.c, ,-, •vim c e p eI'm ILS- 0r's <br /> PROPERTY OWNER INFORMATION: <br /> Name: a1 a r(/` -1-((A-".s-I e c- ,- <br /> Phone(day): 9.5---.)._ - --- (001 34o <br /> Address: 3,-{ (P L( E_. L.... ke_ - City: [.e1,. (c._. ZIP: SS- 3-5(0., <br /> Email and/or Fax: <br /> l -vt�.evt.. cx.•c(. r=ri(o,ce_ 13 w,v\zecyoC , Seeezc <br /> PROJECT INFORMATION: Overall project description: .S;2--0--- , (1-0 r''^-0.- `r"-e e gc- . _ <br /> Type of Project: Any earth movement may also require <br /> ElDoor(s) ElRemodel ❑ Fire Damage MCWD review&permits: <br /> 0 Re-roof,asphalt LI Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 j <br /> ❑ Re-roof,other(specify) 111 Siding E Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> KWindow(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ /Si (-/D <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 aH- <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but <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 dato <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose ar.' <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. <br /> you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: t-' �— Date: V'7 //7. <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />