Laserfiche WebLink
i <br /> City of Orono <br /> BuildingPermit Application for MaintenancO ! Renovation <br /> (windows, <br /> doors, siding, re-roof, et •) <br /> Bf iingAddreas: P :number. <br /> PO Box 66 i 2 <br /> Crystal Bay,MN 55323-0066StamitAddre8V neca�ived• <br /> Q Regl�efwed bjr � . <br /> 2750 Kelley Parkway Abe rgview-ldik <br /> Orono,MN 55356 p <br /> Tn&[Fee <br /> Main: 852-249-4600 Fart 952-2494616 a o ono.mn.u$ <br /> This application form must be completed in full and all required information must be subri,iitted. <br /> Incomplete applications will be returned- (Meese print} <br /> GENERAL INFORMATION: i <br /> Jab Site Address: <br /> Will this be a Parade of Homes,Ramodeler9s Showcase Home aro r olsplay Mom? sr bus sa>�bu <br /> N y8s,a 4m"avant permit is required with ponos Deparb»ent and Cyty Couro epproyst 60 days prtpr <br /> mgwvd untm applloard demonan3tes sufdfclant white podit is ova aWq Non-permaI!ad eymts wX not be Am ed. <br /> CONTRACTOR I APPLICANT INFORMATIOW <br /> Name: Ar�d'er 'i`� <br /> State License# 15C X W1$ Expi tion Date: 31 <br /> Lead Certification Number: — ,l o�g 3 Expii n Date: 14 <br /> 1116 <br /> L� i <br /> (tar worts an"MM trent ware rd>ts&acttsdadsr to.1978 I (cell) <br /> Phone: (a51 oZ (office) i <br /> yq %! "G" t�Jt4SrL' C'tY' :1 a ZIP: 'FS <br /> Mailing Address: [ <br /> Confect Person: Applicant is: / Homeowner (ctde one) <br /> Email and/or Fax: i <br /> PROPERTY OWNER INFO TION: <br /> Name: Li Com, f z %o:7Ac4i <br /> Phone(day): may_ 1 ZIP: <br /> Address: <br /> Email end/or Fax <br /> PROJECT INF'ORNIATION: Ai earl!+tmovemeht niey eq <br /> Type of Project: IYICYVD review pormlts: <br /> ❑Door(s) ❑Remodel ❑Fire Damage Minna ha Creek Distrlct(MCWD) <br /> trek Repoli ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,asp � Deephaven,MN 55391 <br /> p Rwroof,cedar Restoration ❑Water Darrrage Phone: 95271-0580 <br /> $idg [�C3ther:(speclty) Fax: 952*4 1-0682 <br /> d Rei-rcW,other( A I . • ne <br /> D Window(s)) <br /> Overall Proect Description: <br /> ftHmated ConaftiWon Valuation Of Prolect exaiudin Ian $ 3 <br /> I <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all information required or requested by the Building Department,; <br /> The app!cant recognizes that they <br /> Certifiers that the information supplied is true and correctikation bei atma�rs that upo rf hisiher ree•to do so, a staff has no alternative <br /> are solely responsible for submNng a complete app <br /> but to reject it until it is complete; <br /> Some or all of the fnfonmatdorr that you are aslaad to provide on this application rJs classified by State law as edifier private or <br /> Fcordidentiai. Private data is information whiedt generally cannot be given to the bUc but can be Iven to the subject of the <br /> data. Confidential data Is information which generally cannot be gnren to eithe,the public or the subject of the data. Our <br /> purpose and intended use of this Information is to annually update our records and records of other governmental agencies <br /> puired <br /> uose b law. N refuse to su the information thea Gcation m not W issued. <br /> armf� <br /> Anolicarifs Sb)ature: Date: <br />