|
S `.i- �P�`MM 1"`
<br />.. . �� '�"i .._ . V��;�:
<br /> J
<br /> . � -� City of Orono � } � ��
<br /> ."t�a �`a�..:s.,.r.j��
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> ;,;
<br /> Mailing Address: Permit number. � � �
<br /> g,0,�. PO Box 66 �
<br /> � �� 0
<br /> Crystal Bay, MN 55323-0066 Date received: ��/
<br /> ,� �
<br /> � Received by: �
<br /> a � �. �, Sfreet Address: •
<br /> �',�,L�} t �Z'�� �ti 2750 Kelley Parkway Plan review fe �_
<br /> 9kESH�4'� Orono, MN 55356 �
<br />� �— Total Fee: �;�/� �
<br />�-,_ Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ����� Y
<br /> .�
<br /> This application form must be completed in full and all required information must be submitted. �;
<br /> Incomplete applications will be returned. (P/ease print) y
<br /> 2
<br /> GENERAL INFORMATION: ��
<br /> Job Site Address: SG � %� /� � L�,,., `�, Cc nJ s j.3 5 (o ,�;
<br /> Will this be a Parade of Homes, Remodelers Showcase Ho e or other Display 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 parking is available. Non-permitted events will not be allowed. <;�
<br /> .Y�
<br /> - CONTRACTOR/APPLICANT INFORMATION: `
<br /> � �,
<br />��.; Name: �. . \2..a,... �..,<< ° Ciorr� w,. �, :
<br />� ; State License# Zo�, j � 9 g � � Expiration Date: 3 S � 1 2, ,�
<br /> f
<br />�`: Lead Certification Number: Expiration Date: �?
<br />,,,` (for work on homes that were constructed prior to 1978 -
<br />�,.; Phone: (p 12 _ Z�, ( _ ?(o g � (office) q 5 z - �� '1 1 - ? �, rj�j (cell) �`
<br /> ; Mailing Address: 3$a� S�hu� �� City: 5 �; � ZIP: ��U 3
<br />�"
<br />� Contact Person: ��,ti� \.�,, Applicant is: ontractor / Homeowner (Circle One)
<br />�sa` Email and/or Fax: `�,�Z p�,���,�L`<<, U , ��
<br /> <�
<br />��: PROPERTY OWNER INFORMATION: '
<br />�`` Name: �t�.t-�./ �p.c��k o �o� � �t
<br />�s Phone (daY)� Z Z S - Z-$� - 43 a t3 q ��
<br /> " Address: 3�3 d Zlfo'+'� A,,..� /V,�✓, Cit � ZIP: � �j O l� -;
<br />� ` Y�C e a✓�,
<br /> Email and/or Fax �;
<br /> k`:
<br /> � �
<br />�-i. (1
<br />,-= PROJECT INFORMATION: ,,�
<br /> Type of Project: Any earth movement may require w,
<br /> MCWD review&permits: '_�
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) �
<br /> � �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd 4
<br />�;,', �
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 3
<br />�'� Phone: 952-471-0590
<br /> - ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq ;;y��
<br /> ::�
<br /> Overall Project Description: ��
<br /> ��
<br /> Estimated Construction Valuation of Project(excluding land) $ ,S 0 o d, o0 5=
<br /> �.�
<br /> -� APPLICANT ACKNOWLEDGEMENT: '�
<br /> �.�
<br /> r ;:' • Agrees to provide all information required or requested by the Building Department; �
<br /> �">,
<br />�'` • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they �
<br />,.�;
<br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative i�
<br />�.; but to reject it until it is complete; �:
<br /> • Some or all of the information that you are asked to provide on this application is dassified by State law as either private or ,s�
<br />';; confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the �
<br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
<br /> a i purpose and intended use of this information is to annually update our records and records of other govemmental agencies ,;��
<br />�- re uired b law. tf ou refuse to u I the information,the a lication ma not be issued. �:�
<br />��: `�
<br /> x;
<br /> ApplicanYs Signature: � � Date: � � ��,
<br /> Last Updated: 08-09-2011
<br /> .�� z:
<br /> �
<br /> �,: ,
<br /> .� _-- -� �. .___� r_ _ --,- --
<br />
|