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<br /> City of Orono �,�.
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<br /> Buiiding Permit Application for Internal Work �
<br /> (windows, doors, siding, re-roof, etc.) ;3
<br /> Mailing Address: ��
<br /> Permit number:
<br /> �,L,�,� PO Box 66 �
<br /> 0,�,\ Q Crystal Bay, MN 55323-0066 Date received: ;tik
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<br /> Received b �_,
<br /> � ���',��.��� �, Street Address: Y�
<br /> a'� ' �' e� ti`�' 2750 Kelle Parkwa . �
<br /> � ` � �� y Y Plan review fee: �,,
<br /> 9kESH04 Orono, MN 55356 ,�
<br />' Total Fee: F F
<br />'`' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �-��
<br /> � This application form must be completed in full and all required information must be submitted. �
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<br />�;�' Incomplete applications will be returned. (Please print) �
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<br /> GENERAL INFORMATION:
<br /> � Job Site Address: ��
<br />�; Will this be a Parade of Homes, Remodelers Showcase Home or other Dis la Home? 'y
<br /> p y ❑ Yes ❑ No <-
<br /> /f yes, a special event permit is required with Po/ice Department and Crty Council approva/60 days prior to the event. Shuttle bus service wi/l be �..
<br /> requrred unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed.
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<br />�� CONTRACTOR/APPLICANT INFORMATION: ��
<br />` " Name: �--oss �;cT�n_1G2�' �C.� �
<br />° State License# �O y��,�t�2� p� 2 �Z�
<br /> Ex iration Date: - .3 - o r
<br />,== Phone: c��Z-?���- �SCv(�' (office) " cell)
<br /> � Mailing Address: j - ^ ,�-,,o � -,(',�, Cit : l c���� �. ZIP: ,�����-
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<br /> Contact Person: `T-'�Lc.^;-vo�, -���� Applicant is ontrac / �Homeowner (CircleOne) -
<br />�� Email and/or Fax: -���,.,o f�� �:�c,�-�.,�, ,�<-� L�E." �
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<br />#:.: PROPERTY OWNER INFORMATION: I/ / �
<br /> Name: '�,�-� �r'�'.��..>,�^��2 T1LL�,•.�SC.��M���l�
<br />�; Phone (day): `���iy�l 7��3 ;�
<br />�=:r Address: Zo(�' S�Lfyl/1, ��tJ�-"'r CItY: O�t�/'JU ZIP:r`�!� :,�
<br /> Email and/or Fax � �
<br /> g�`�' �v�K I F�� .� . Ut�l n-,,c/�4-d C�'`G1�l..��-u/`-'1 �
<br /> �
<br /> PROJECT INFORMATION: k�
<br /> Type of Project: Any earth movement may require }�
<br />��°'' MCWD review&permits "�
<br /> ❑ Door(s) ❑ Remodel ❑Water Damage �
<br /> ,k
<br /> Minnehaha Creek Watershed District(MCWD) �
<br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391 �
<br />�_ ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 �
<br /> � Fax: 952-471-0682
<br /> >- Re-roof ❑ Fire Damage www.minnehahacreek.orq �
<br />� Overall Project Description:
<br /> 4�
<br /> Estimated Construction Valuation of Project(excluding land) $ 2,����Z `>_' r;�
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<br /> APPLICANT ACKNOWLEDGEMENT: ��
<br /> • Agrees to provide all information required or requested by the Building Department; �
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<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 /> f` confidential. Private data is information which generally cannot be given to the public 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 governmental agencies ��
<br /> re uired b law. If ou refuse to s I the information,the a lication ma not be issued. ���
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<br /> A licant's Si nature: � ��
<br /> Pp 9 LL�� �-�.� Date: �j ��% ���U/C)
<br /> Last Updated: 05-04-2009 �^�
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