Laserfiche WebLink
City of Orono <br /> Buildir�g Permit Application for Maintenance/ Replacement/ Remodel — Residential ONLY <br /> �vs,,, <br /> � A' Mailing Address: � ?—Q Q <br /> D,y\ PO Box 66 Permit number: � ���O <br /> 0 �, Crystal Bay, MN 55323-00 �- Date received: �l v� � 7 <br /> ,i <br /> �1 � 1 � � Street Address: '�� Received by: <br /> \'� � 2750 Kelley Parkway (�I�,� Plan review fee: <br /> � �,�' Orono, MN 55356 � ._, <br /> � �kfSHO� �,�� �� <br /> ��_ __ Total Fee: � <br /> Main: 952-249-4600 Fax: 952-249-4616 v.,.,�rY <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 /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> /f 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 INFORMATIO,NJ. , <br /> Name: « ��,� � � Q <br /> Phone (day): �� � ' <br /> �, �� <br /> Address � City: ���c�� � ZIP: � �j � � <br /> Email and/or Fax: ��J����,� yl � ��� f-� ��+ :�e . <br /> PROJECT INFORMATION: Overall ro�ect descri tion: �"';�1 � �3••c sc'wt ��r� /"�E'�� <br /> P J p S 1�'�'c' �. <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review &permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(speclfy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) �N����• � rr��� � �r�3�., ��r�_i <br /> Estimated Construction Valuation of Project(excluding land) $ d4�����, <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 information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the information, the a lication ma not be issued. <br /> ApplicanYs Signature: i '��-'L`'� Date: �- <br /> Owner's Signature: ���L Date: Cl���'�l � <br /> Last Updated:January 2016 <br />