HomeMy WebLinkAbout1995-006754 - tear-off/re-roof PFRMIT
.;ITY OF ORONO " � � � PERMIT TYPE:
2750 Kelley Parkway- P.O. Box 66 Permit Number. -
Crystal Bay, Minnesota 55323 ' -
(612) 473-7357 Date Issued: - - - -
SITE ADDRESS:
DESCRIPTION:
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FEE SUMMARY:
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CONTRACTOR: -- - - -- -;� OWNER:
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APPLICANT%PERMITEE SIGNATURE ISSUED BY:SIGNATURE
CZTY OF ORONO -� 33tJii.DZNG PERMIT APPLICATION
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Total Fee• $ � � ��-' Date Received:
Date Approved:
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Entered By: .: _<., �
Permit tt: �. ,'_� `!
ALL INFORMATION MIIST BE SIIBMITTED IN FIILZ� BEFORE PI�N REVIEW WILL BE STARTED
(See Chec}c-cff List Enclosed)
-------------------------
THE APPLICANT IS: (circle one) OWNER o CONTRACTOR
JOB SITE ADDRSSS: ��� � �� �������L� �1� ZIP: 7 �.S���
(work)
N� OF OWNER: �/9"C�/f ����' � PHONE: (home)���_�-�7.L
MAILING �DxEss: �/G' S �s. ,�C�c ti'���c ��� cz�: �,�/-�'�/a zzP: �5 3y/
CONTRACTOR: 5��� /� �f l N C� PHONE: ��--5 l O ���
MATLING �Dx�ss: L/l DO �XC�LSio/� ���>cz�: Sl' C�u�s �ij-.��Z1P: 5" SY��
STATE LICENSE: '� ��' j C%
ARCHITECT/ENGINEER: PH��'
MAILING ADDRESS: CITY: ZIP:
N�ME: REGISTRATION n
TYPE OF WORR: New Addition Accessory Structure Move
Demo Remodel/Alteration_� Renovate Land Alteration
PROPOSED WORR (describe in detail) :��� ��a�/' �� .�C �`'��� /fG'e���
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, STORIES: SQ. FEET OF EACH FLO�Rs
NO. OF BEDROOMS: G�GE STALLS: ATT. DET.
ESTIMATED CONSTRIICTION VALIIATION (ezcluding land) : $ �J �GC%
I hereby apply for a building permit and I acknowledge that the information
above is complete and accurate; that the work will be in conformance with the
ordinances and codes of the City and with the State Building Code; that I
understand this is not a permit and work is not to start without a permit; and
that the work will be in accordance with the aporoved plan.
� APPLICANT'S SIGNATURE: i.�. �1,�1��`�✓ DATE: �
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�y�A ,,,; Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices
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� _ � �Y��• On the North Shore of Lake Minnetonka
DATA PRIVACY ADVISORY
In accordance with M.S. 13.04 , Subd. 2 , "Rights of subjects of
data", we would like to inform you that your request for a permit or
license from the City of Orono or any of its departments may require
you to furnish certain private or confidential information.
You are notified that:
l. The information you furnish will. be used to determine your
qualification for the permit or license requested.
2. You may refuse to supply data, but refusal may require that
the City deny the permit or Iicense.
3. The information may be shared with other Iocal , s�ate or
federal agencies to the extent necessary to process the permit or
Iicense.
4. If your requested permit or Iicense requires Councii. ac�ior.
to approve, some information may become public.
5. You have certain rights under M.S. 13.04 to review private
data on yourself.
6. Your full name is required to proc�ss this application or
permit.
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Ad ress
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City State Zip
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Phone
I understand my rights as st �ed above.
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Si ature .
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BUILDING& ZONING—473-7357
• ADMINISTRATION& FINANCE—�373-7358 • PUBLIC WORKS—473-7359
ASSESSING