HomeMy WebLinkAbout2010-00147 - addn/remodel/repair , CITY OF ORONO PERMIT IVO.: 2010-00147
2750 KELLEY PARKWAY
ORONO, MN 55356- �ATE ISsuEn: 03/22/2010
952 249-4600 FAX: 952 249-4616
ADDRESS : 2695 COUNTRYSIDE DR W
PIN : 04-117-23-13-0005
LEGAL DESC : OLD CRYSTAL BAY ROAD ADDN
: LOT 005 BLOCK 003
PERMIT TYPE : ADDITION/REMODEL/REPA[R
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDN /REMODEL/REPAIR
ACTIVITY : 434-RESIDENTIAL
VALUATION : $ 15,000.00
NOTE: SEPERATE PGRMITS REQU[RED: PLUMBING)
INTERIOR BATHROOM REMODEL-NO STRUC"I�URAL CHANGES
APPLICANT
PERMIT FEE SCHEDULE 265.50
WATER STREET HOMES LLC STATE SURCHARGE(VALUATION) 7.50
305 MINNETONKA AVE S TOTAL 273.00
WAYZATA, MN 55�91-
(952)474-6160
Minnesota State License#: 20390906
OWNER
PETERSON, DON
2695 COUNTRYSIDE DR W
LONG LAKE, MN 55356-
AGREEMENT AND SWORN STATEMENT
The work for which this permit is issucd shall be performed according to �
the approved plans and specifications,applicable City approvals,and the
State Buiiding Code. This permit is for only the work described and does
not grant permission for additional or related work which requires separate
permits. All provisions of laws and ordinances governing this type of work
shail be compied with whether or not specitied herein.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days of the date of issuance,or if construction is
suspended for a period of 180 days at any time after work has commenced.
The applicant is responsible lor assuring all required inspections are
requested in conformance with the State Building Code."I�his permit may be
revoked at time for cause.
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Applicant Permitee Signature Date Issued By Signalure Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
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City of Orono
Building Permit Application for Internal Work
(windows, doors, siding, re-roof, etc.)
�____� Mailing Address:
�,�,�\ PO Box 66 Permit number: /!�- (.Y�/S��
� 1 Crystal Bay, MN 55323-0066 Date received: �/�J /D
' _ ��� �\�
�� �� ` a,I� Street Address: Received by: _
�y"-��
` Gti�' 2750 Kelley Parkway Plan review fee: . ` � � � ,
\�kESFi04'� Orono, MN 55356 �"�`'
_ _- "�" Total Fee: p���, ��
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Main: 952-249-4600 Fax: 952-249-4616 www ci.orono.mn.us
This application form must be completed in full and all required information must be submitted. (`' . ;1 r �
Incomplete applications will be returned. (Please print)
GENERAL INFORMATION:
Job Site Address: z�s��'� c��,, �>� „�,,�� ,�,�dv� w . Qi�'��v<;
Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 0 No
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
required unless applicant demonstrates su�cient on-site parking is available. lVon-permitted events will not be allowed.
CONTRACTOR/APPLICANT INFORMATION:
Name: w�t�� �,� 5;;� �FT ' �.<,�� LL
State License# Z o 3 9 0 9 0 � Expiration Date: 3 3� �2 oi o
Phone: t�,2 8s a � yooZ (o�ce) Z�/L2 8�o � �oaZ (cell)
Mailing Address: 3o�,S �i�nr�v��nn ,�.� � S. Ci : l� ZIP: s,f' J
Contact Person: j� ` C,�z�.� Applicant is: ontracto / Homeowner (Circle One)
Email and/or Fax: !�,c,�z � �c,;�P-��.-� s�2 s �r= �o ry,�S - �a �
PROPERTY OWNER INFORMATION:
Name: 6�o.v � 1�.2�sn�v� ���2.��✓
Phone (day): 9�z yS7 � 9 y� L/
Address: Z�9S C�✓�s�,r��. D2�v�' (�/ City� a2aNb ZIP� S�-3sCo
Email and/or Fax A�N c- P�P��GSsyN c� tr/r��s''/L . o.-L.
PROJECT INFORMATION:
Type of Project: Any earth movement may require
MCWD review 8�permits
❑ Door(s) (� Remodel ❑Water Damage
Minnehaha Creek Watershed District(MCWD)
❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
Deephaven, MN 55391
❑Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590
Fax: 952-471-0682
❑ Re-roof ❑ Fire Damage www minnehahacreek orq
Overall Project Description: �mo,o�-` ��c i5»�✓7r r3.1,'zf -S� ,�-7t�/,r�,2 �Lr/� � �o S7�uC'Izi�� iNv¢�v`�a .
Estimated Construction Valuation of Project(excluding land) $ � , doa
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 for 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 Gassified 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 annually update our records and records of other governmental agencies
re uired b law. If ou refuse to su I the information,the a lication ma not be issued.
ApplicanYs Signature: '�"„G�-C� � Date: 3 �i..5-,��0/0
Last Updated: 05-04-2009