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2017-01564 - addn/remodelrepair
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Ferndale Rd W
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1065 Ferndale Road West - 02-117-23-43-0021
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2017-01564 - addn/remodelrepair
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Last modified
8/22/2023 4:10:32 PM
Creation date
1/19/2018 3:46:55 PM
Metadata
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Template:
x Address Old
House Number
1065
Street Name
Ferndale
Street Type
Road
Street Direction
West
Address
1065 Ferndale Rd W
Document Type
Permits/Inspections
PIN
0211723430021
Supplemental fields
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Updated
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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 /> CoA Mailing Address: Permit number: 0?0,7-.4,5ro� <br /> PO Box 66 <br /> O Crystal Bay, MN 55323-0066, , l� Date received: /���"/, <br /> Street Address: �" �� Received by: <br /> yF 2750 Kelley Parkwa I Plan review fee: <br /> t o Orono, MN 55356 <br /> �'rfSHC�� Total Fee: if / Sot g3 <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: JQ(>c 1r2^-0a L rL YZa(-i) 14- . <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes Ri 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 INFORMATION: <br /> Name: H(1jc. m C <br /> State License# Bc 9 c Z o 69 Expiration Date: 3-3 1 -1 g <br /> Lead Certification Number: n/IN i - I p B9 -Z Expiration Date: 9-Zo _z i <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 7(2-ZZz_6 6 f 3 (office) 76)- -QZZ - ce,9 5 c,, <br /> Mailing Address: I I(00 (...k.). gi viz./Lgo/4_6 City: C,r"p,_I .- ZIP: 5'5-) 16 <br /> Contact Person: HA tt 7 L L.1el 14 vet:el__ Applicant is: n r--ac j/ Homeowner (circle one) <br /> Email and/or Fax: !nine. C. titi e_a a A it 10 w-S . co III <br /> PROPERTY OWNER INFORMATION: <br /> Name: L13i3Y 6 a To 4-. <br /> Phone(day): 5/6 35.0 -Z7 6, 1 <br /> Address: I U66- r g a..0-,124 LPL.. /+u w City: 14,4 ;214T 4 ZIP: 55 1 <br /> Email and/or Fax: L i d i, �4 e +c.,r c_ 0,A-c • ccs M <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) ElSiding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) Li www.minnehahacreek.orq <br /> Os? <br /> Estimated Construction Valuation of Project(excluding land) $ -- 000 <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..1 t e i'formatio ,the -••lication ma not be issued. <br /> J / . <br /> Applicant's Signature: G Date: l I —2-�' <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />
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