|
. x...r � r ��� �,. � _ ��
<br /> . . . L��� �,e
<br /> �
<br /> . - � City of Orono ��
<br /> R� Building Permit Application for Maintenance / Replacement / Renovation �
<br /> : (No structural expansion. Only windows, doors, siding, re-roof, etc.) ��
<br />`� Mailing Address: ��'
<br /> �O�O PO Box 66 Permit number: �
<br />�;:�".' Crystal Bay, MN 55323-0066 Date received: -a
<br /> Street Address: Received by:
<br /> y�, ` 2750 Kelley Parkway Plan review fee: "
<br /> ��,L Orono, MN 55356 +�
<br /> ��kESHo Total Fee: �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �
<br />{ .:
<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 /> fi��
<br /> : Job Site Address: /�/`{? Ocf-�� %��.;✓� �%�.-�•.�� rvr r� �S—3 S � `�
<br />�`� Will this be a Parade of Homes, Remodelers Showcase Home or other Disptay Home? ❑ Yes 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 parkrng is availa6le. Non-permitted events will not be allowed. 'tt
<br /> e:' ,;t:�
<br />� , CONTRACTOR/APPLICANT INFORMATIO : I �
<br /> Name: i)/( � �-i��-�\ C��� �..�s �u��r �
<br /> State License# ��U E, � �j S-E, Expiration Date: ; �j �
<br /> Lead Certification Number. Expiration Date: '�
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) a _ � _ �j ��� (office) 9� �-�`i`�i`� �� /�S �
<br />��r
<br /> Mailing Address: , �3G �' ��,.� ,/�.,_,� City: -�Q w� ZIP: �5�3 L�; �
<br />� Contact Person: , � a, �s Applicant is: on�t�Cta�—_/ Homeowner (Circle One)
<br /> Email and/or Fax: ��i� ,r1,� f(�S� t�w2a: � - <<� ""�'
<br /> �
<br /> t��� PROPERTY OWNER INFORMATION: �'
<br />�:, Name: y�,l�f G� �- ��,,_. Q�-`� F�
<br /> Phone (day): �(2-8'S�'—fo j,S'
<br /> Address: ��{¢-7 c�../c �r���-e Clty: (�,��,�,�, ZIP: �5 3S6 ��
<br /> Email and/or Fax:
<br /> !^1 O w "�� �—�t �� tvt C ��.�'! C�6t �c 5
<br /> PROJECT INFORMATION: Overall project description: 'ti'����J r� (� �F.�,:.� �._-� v�-��;; -, l��-� � °� ��w.
<br /> �e
<br /> � Type of Project: Any earth movement may also require
<br /> [f Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits:
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) a�
<br /> 18202 Minnetonka Blvd =�
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �
<br /> Phone: 952-471-0590 �.�
<br /> E,,' ❑ Re-roof, other(specify) ❑ Siding ��•+��. ❑ Other: (specify) '�
<br />��j: Fax: 952-471-0682 �
<br /> , ['�Window(s) www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ ��vo a � �
<br /> K.:y `�
<br /> �
<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 infor tion is to annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I the i ormati n,the lication ma not be issued. �
<br /> ApplicanYs Signature: � Date: /�(�lzU�3
<br /> Owner's Signature: Date: `
<br />�.:' Last Updated: 03/06/2013 k
<br /> , . �
<br /> �
<br /> �,.
<br /> ,
<br />
|