|
To; 9522499616 From; Leqacy FAX 5-15-13 11;06am p, 2 of 2
<br /> { •
<br /> City of Orono '
<br /> Building Permit Application for Maintenance I Replacement/ Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) /� �
<br /> �A, Maifing Address: -� '''�" - � j `
<br /> �' �YQ PO Box 88 Petrtt"'1f�umber� - �
<br /> -•- ti�
<br /> Crystal Bay,MN 55323-6066 17at�;r��elved.:`..,;,.,�- . �,�;;:;;:..- ,..:::��-
<br /> 5tree!Address: Rece�y�d py
<br /> r:
<br /> � �` 2750 Keile Parkwa '�� 4
<br /> � • Y Y Plao reyl��f¢e -
<br /> � Orono,MN 55356
<br /> �'���'Sttn�� .�'a��Fee '�/ �.�����_. : I
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn,us ,:,.�..: ....,...._,,...,.... ,...:_�v_�_ . `
<br /> This application form must be completed in full and all required informafian must be submitted.� '
<br /> Incomptete appllcattons wlfl ba returned. (Please prinfj �
<br /> GENERAL INFORMATfON: ;
<br /> Job Slte Address: ?.�o..� �� �'.f�'��-.�-�°'., �1"`iP��'F' �.,��' �, �'���'l;�; �
<br /> Will thls be a Parade of Homes,R�modelers Showcase Home or other Display Home? ❑Yes `� No '
<br /> If yes,a spec/a1 event parmlt Is requhed wlth Polke Department and Clly Councll approvaf 80 days prlor to ye event ShutUe bvs serUice wlti be �
<br /> reguUed untess appiicar�demanstrefes sufhcient on-site pa�king is avalla6le. Non-permitted evants w!!!not 6e allowed
<br /> CONTRACTOR!APPLICANT INFORMATI�N: I
<br /> Name; �,....c.?��,.s:._.t1�� �,�.`���'�'(���-�,•�E L,,��'� ��1,----.�_
<br /> State License# J�r.'�, �' �.�� , `� ?�. Expiration Date: �:�,,� �,:�;t.:� j
<br /> Lead Certification Number. "� .�. -� �` +,�r `���y•. + Ex iration Date: � �, + �
<br /> � �;'�', o a � a p 8��c�i
<br /> (for work on homes that we�e consfructed prlor to 1978
<br /> Phone: (cel!) ; '�� e- — `�} {offica) �._'�.� " i C3 r , :-:�� � �
<br /> MailingAddress: t � r �;-f� �> � ` 31 � C4ty. a� t^�y�v t�'..-, ZIP: "' t� '-- �
<br /> Contact Person: r"�,�1 ' Applicant is: Gontractor 1 Homeowner
<br /> �.,���� � (Circle One)
<br /> Emall and/or Fax: �,� `E p '"` ��r �' ,.�.� rUt�' �.�. ' �,tyy�,^
<br /> PROPERTY OWNER I FORMATIOW:
<br /> Name: �_ � �jx
<br /> Phane(day): ,�� �� ��
<br /> Address: i.r a � <ev �_ ��CR City, ;��,� q Z1P: �����' �
<br /> S._
<br /> Email andlor Fax:
<br /> PRCIJECT INFORMATICI(V: Overall ro ect descri tion: �
<br /> Type af ProJect: Any earth movement may also require I
<br /> ❑Door(s} ❑Remodel ❑Fire Damage MCWD review 8 permits:
<br /> �Re-roof,as halt Mlnnehaha Creek Watershed District MCWD �
<br /> p ❑RepalP ❑S#orm Damage � � (
<br /> 18202�Ifnnetanka Bivd
<br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391
<br /> ❑Re-raof,other(specNy) ❑Siding ❑Other.(specify) Phone: 952-471-0590 �
<br /> Fax: 852-471-0682
<br /> ❑Window(s) www.minnehahacreek.ora
<br /> Estimated Canstruction Vaivation ef ProJect{excludtng land} $ „�c�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provlde all informetion required or requestad by the Building Department;
<br /> • Certifies that the information supplied is vue and correct to the best of his/her knowiedge. 'fhe applicant recognizes that they are �
<br /> solely responsible for submitting a complete applicaUon 6eing aware that upon failure to do so,the staff has no akemative but to I
<br /> reject it until it ia complete; !
<br /> • Some or ali of the informatian that you are asked to provide on this applicatlon is dassified by State law as either prlvate or
<br /> confldential. Private data is infortnation which generally cannot be given to the pubtic but can be given to the subject of ths data.
<br /> Confidentlal data Is informa6on which generalty cannot be given to eit�er the publlc or the subJect of t�e data. Our purpose and �
<br /> intended use of this information is to annually updete our recotds and records of other govemmental agencies required by taw. If i
<br /> ou refuse to su I the Inform on,the a tication nwYb sued. i
<br /> ` ; , k.--�;. 'r .y` .� ' ¢ � �
<br /> ApplicanYs Signature: � Date: '� � a ��
<br /> f..
<br /> Owner's Signature: Date: �
<br /> Last Updated:03/06/2013 I
<br /> i
<br />
|