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<br /> City of Orono �
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<br /> _ . � Building Permit Application for Internal Work ���� ��
<br /> (windows, doors, siding, re-roof, etc.)
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<br /> Mailing Address: Permit number: Q--��7
<br /> �,L,0,� PO Box 66
<br /> Q , � Crystal Bay, MN 55323-0066 Date received: �l /�
<br /> �
<br /> ''� �ppp +`�� Received by:
<br /> � Mf� �,����,;; �, Street Address: -
<br /> � �� ° a� Gti`�' 2750 Kelley Parkway Plan review �:
<br /> L�kESH�4� Orono, MN 55356 �
<br /> Total Fee: "�
<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.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: �
<br /> °, Job Site Address: �Zv �� � ��:n��, C�,u�f �,
<br />� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No �
<br /> 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 b �r
<br /> required unless applicant demonstrates sufficient on-site parking is availabfe. Non-permitted events will not be allowed.
<br />$�, CONTRACTOR/APPLICANT INFORMATION: �
<br /> Name: �"�"o S� �,xT�2,l c�!\:� , l�C.. L . �
<br /> State License# Z�� 3 ,v��Z ' Ex iration Date: �
<br /> `-�s_' P� �-3�-Z-o/Z—
<br /> Phone: �,p�Z,- �2 _ Q�c� �< office) cell �
<br /> Mailing Address: t�i t ND qL C�n.�l� Cit : ,�a��,,�; ZIP: S S3 �"��
<br /> �� Contact Person: ��,�,�„ A licant is: ontractor / Homeowner
<br /> �. � pp (Circ�e one) �
<br /> Email and/or Fax: �j ",rz„E_Ut�;L,n�"F��ss�;Xi�,,c.,,v,L,S , Gc,r'l
<br /> r; PROPERTY OWNER INFORMATION: �
<br /> Name: Sc r�-� � 1'`�✓�U/ � �')c=�25'T-.�.�M
<br /> �
<br /> Phone (day): �
<br /> Address: Z o �� v��,� ��2rt-- City: C�20�1 b ZIP: ' �.���p �
<br /> Email and/or Fax �
<br /> PROJECT INFORMATION: ,,,
<br />� Type of Project: Any earth movement may require .�
<br />� MCWD review&permits o-$a
<br /> ❑ Door(s) ❑ Remodel ❑Water Damage �
<br />�t;: 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 />�.. �
<br />� ; Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description: 7"'E,c�_.e�� � 2�-,� ��,c
<br />� Estimated Construction Valuation of Project(excluding land) $ ZS �O(o �? w�
<br />�.
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<br /> APPLICANT ACKNOWLEDGEMENT: �
<br />�, • Agrees to provide all information required or requested by the Building Department; �,�
<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 a l l o f t he in formation 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 �
<br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
<br /> ��
<br /> purpose and intended use of t � rmation is to annually update our records and records of other governmental agencies �
<br /> re uired b law. If ou ref to su I the information, the a lication ma not be issued. �
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<br /> Applicant's Signature: Date: � g�` �-�-�'�O �
<br /> G� Last Updated: 05-04-2009 ��
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