2013-00899 - bathroom remodel - Laserfiche WebLink

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� ` City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) Mailing Address: /3_� �f� �O�O RE('iE�VE� PO Box 66 Permit number: / Crystal Bay,MN 55323-0066 Date received: �' J� f � , � '�AUG � O 2 O�3 Street Address: Received by_ � 2750 Kelley Parkway Plan review fee: `�'-��F�F„��`\'CITY OF ORONO orono,MN 55356 Main: 952-249-4600 Fax: 952-249-4616 Total Fee: '� l�,5� This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: �� :�,G P 11 l:�S A 1�,1 i (�,. �.X(,C.,�' \ O� ��i `�S�'�� Will this be a Parade of Homes,Remodeters Showcase Home or other Display Home? Yes No !f yes,a specia/event permit is required wifh Police Department and City CouncF!approva/60 days prior to the event. Shutt/e bus service will be required unless app/icant demonstrates sutficient on-site parking is available. Non-permitted events will not be a//owed. .,---------�-. CONTRACTOR rA�PLICAN'T INFORMATION: Name: 1�'1 R�,��. � ! � G �. State License# Expiration Date: Lead Certification Number: Expiration Date: (tor work on homes that were constructed prior to 1978 Phone: (cell) (offlce) Mailing Address: �. . �— � City-�x�-�L �('i4L ZIP: � `J' � � 1 Contact Person: Iv�n �� E Applicant is: Contractor / omeown (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: _1`1�l� r: @M � � G i:... Phone(day): � Address: 'a,,'� '�.l:V P �t�E f� � 4>, i�'� � �"�. City: `�k l-.t i_S�Gf�ZIP: � '� 3��1 Email and/or Fax: PROJECT INFORMATION: Overall ro"ect descn tion: � �C �� f�c 1"�G `7 G L' Q4� � ^v`v�:�.(�, v a �r�� Type of Project: Any earth movement may also require ❑Door(s) �Remodel MCWD review&permits: S 1 N K 5 ❑Fire Damage ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) � �l.G ❑Re-roof,cedar 18202 Minnetonka Blvd ❑Restoration ❑Water Damage Deephaven,MN 55391 1' � ❑Re-roof,other s Phone: 952-471-0590 �T J ( pecify) ❑Siding ❑Other.(specify) ❑Window(s) F�: 952-471-0682 Estimated Construction Valuation of Project(excluding land) $ V C_> '% APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; . Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible fo�submitting a complete application being aware that upon failure to do so,the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annuall ate our records and records of other govemmental agencies required by law. If ou refuse to su I the i o tion,the a 1' �on a not be issued. Applicant's Signature: �t��-- / ' Date: ` .�� "� � � Owner's Signature: /� ��C Date: � �'�� -� Last Updated:03/06/2013