Laserfiche WebLink
0612012017 13:58 I:AX) P.0011001 <br /> City of O ro n� <br /> Bullding Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �QA rO Mailing Address: Permit number: dZI <br /> <V PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received —,7-1-17 <br /> Street Address: Received by: <br /> ti 2750 Kelley Parkway Plan review fee <br /> F <br /> 7 � Orono, MN 65356 <br /> Main: 952-248-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fea: <br /> This application form must be completed In full and al! required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: Q <br /> Job Site Address: 1a�5 d �� !� ✓�c. � `�l� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other DlspI y Home? Yes 7No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bu rvrce will be <br /> required unless applicant demonstrates sufficient onsite parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �/A a, <br /> State License# .7 Expiration Date: <br /> Lead Certification Number: �����cf" 2 Expiration Date: �1 <br /> (for work on homes that were constructed prior to 9978 <br /> Phone; (cell) -7 G (office) <br /> Malling Address: City: e ;v� zip: <br /> Contact Person: r•.` Applicant is; � / Homeowner (ciroh•0n•) <br /> Email and/or Fax: r� �� �.r"v. 3[o �a <br /> PROPERTY OWNER INFORMATIO <br /> Name: iLl�-- b .pLLAL11 . <br /> Phone(day): -• nnab <br /> Address: ,<� , n1�1 CSS l City: ` zip: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: L 5 <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage <br /> 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) Slding ❑ Phone: 952-471-0590 <br /> Other: (specify) Fax; 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) $ chra <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 /> you refuse to supply the Information,thea (i ation mly not be issued. <br /> Applicant's Signature: Date: .1 <br /> Owner's Signature: Date: <br /> Leet Updated;January 2016 <br />