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 /> ^^,, Mailing Address: Permit number: v-004276 <br /> Sl.- VO PO Box 66 _ g <br /> Crystal Bay, MN 55323-0066 &.4 Date received: j � U <br /> Street Address: <br /> �1�1��\o Received by: `� <br /> y 2750 Kelley Parkway Plan review fee: <br /> e L <br /> l4kfSH00- Orono, MN 55356 <br /> Total Fee: /L� g° <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 7 ' <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 /> GEJobNERAL SiteAdd Address: <br /> <o s i Tfi���"•- ��' O�Or�^ JC <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? ❑Yes X 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: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that'were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: DA v\ U z_q <br /> Phone (day): Q5 Z5")- VI 9uJ <br /> Address: 30fkl F:ItAV LOA) City: 0)2_0.A ® ZIP: j53s b <br /> Email and/or Fax: 1 T Lk-7 ____34,‘SAI Co vn <br /> PROJECT INFORMATION: Overall project description: 4R4Z.010VC WALL <br /> Type of Project: Any earth movement may also require <br /> Door(s) ISI Remodel O. Fire Damage MCWD review&permits: <br /> ElRe-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar 0 Restoration 0 Water Damage Minnetonka, MN 55345 <br /> 0 Re-roof, other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 1 002-0-..APPI-ICANT ACI�NQWLEDGgMPNT: <br /> la 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 generall .nnot be given to either the public or the subject of the data. Our purpose and <br /> intended useof this information is to annu- upda - our records and records of other governmental agencies required by.law. If <br /> you refuse to suppl -m. .• e.a•'cation ay not be issued, <br /> Applicant's Signature: /. f �` Date: J(i (i b <br /> ' II <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />