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<br />��� City of Orono ��
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<br />�� Building Permit Application for Internal Work w
<br />�
<br /> ��' (windows, doors, siding, re-roof, etc.) t�
<br />��
<br />�°- Mailing Address: �j`b — D/�
<br />� : �,L,0,� PO Box 66
<br /> Permit number:
<br /> *�' 0 , O Crystal Bay, MN 55323-0066 Date received: / /�
<br /> � � �$�` � � Received by:
<br /> �✓�'e���� �.'I StreetAddress:
<br />��;� �'� �� �"" ti�' 2750 Kelley Parkway �/� �
<br /> , o Plan review fee:
<br />��' �9kESFI�4"� Orono, MN 55356 �
<br /> 9
<br />� -- Total Fee: / �
<br />�. Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us / ��Q• � ?�
<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 />� r Job Site Address: ' /� ��5�? �� %2/�
<br />��
<br /> � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br /> s� <, If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service ill be
<br />�F. required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �
<br />�k� CONTRACTOR/APPLICANT INFORMATION:
<br /> ` Name: �1 1� S I� ��1 ��i�.�C�
<br /> State License#
<br />�«� �—� �7 5' Expiration Date: "3 — 3 j ��
<br />� ' Phone: S�— � � � S- � office b/� -�56�7 3 �c cell
<br />� ; Mailing Address: G�- � � i2, � 1D� Cit : ,'n,� � ZIP:
<br /> S�.
<br />�{" Contact Person: v►� Applicant is: Contractor ! Homeowner (Circle �e�
<br />�,; Email and/or Fax: 1,�1,>i rz,2,�, R .� /n 7�-� A o L C �v�,� -�
<br />��.�,
<br />,�r_:
<br /> �' PROPERTY OWNER INFORMATION:
<br /> Name: �2 t; n c-�S v �--�
<br />��, Phone (day):
<br /> Address: City: ZI P�
<br />��=° Email and/or Fax
<br />.ti�;:
<br /> ` PROJECT INFORMATION:
<br />�`� T e of Pro'ect:
<br />�;�j�:: YP J Any earth movement may require
<br />���: MCWD review 8�permits
<br /> ❑ Door(s) ❑ Remodel ❑Water Damage =
<br /> " Minnehaha Creek Watershed District(MCWD) '
<br />:,� ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br /> E��s Deephaven, MN 55391 �
<br />`` ❑ Sidin
<br /> N,,i,, g ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590 'h
<br /> �.
<br />��� Re-roof Fax: 952-471-0682 "
<br /> ❑ Fire Damage www.minnehahacreek.orq
<br />�, verall Project Description: �
<br />,�,r Estimated Construction Valuation of Project(excluding land) $ � D -� .
<br /> E� � ��
<br />�* APPLICANT ACKNOWLEDGEMENT: �
<br /> ' • Agrees to provide all information required or requested by the Building Department; ��
<br /> ¢s��
<br /> '�'+,,
<br />��'` Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they ��
<br /> �; • are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative �,�
<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 classified by State law as either private or ;��
<br /> confidential. Private data is information which generally cannot be given to the pubfic 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 /> = purpose and intended use of this information is to annually update our records and records of other govemmental agencies �
<br />�- re uired b law. If ou refuse to su I the inf rmation, the a lication ma not be issued.
<br /> �:.
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<br />� ApplicanYs Signature: Date: � Y � � + r�
<br /> �
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<br />�, Last Updated: 05-04-2009 �,�
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