|
�" '����5' �, � �r.��e�� � � --��E ,^�}. ,
<br /> .... �,>' � ,�
<br /> ; ��
<br /> 3" y
<br /> tS 'c�
<br /> y City of Orono � k���� ��� �
<br /> . � , i�,�����
<br /> �� "��t
<br />��� Building Permit Application for Internal Work �
<br />� ' (windows, doors, siding, re-roof, etc.) �
<br /> �
<br /> Mailing Address: Permit number: �
<br /> �v�,� PO Box 66
<br /> 3�
<br /> Q � Q Crystal Bay, MN 55323-0066 Date received: �
<br /> a ��',��:"y �, StreetAddress: Received by: �
<br /> ;� �'�n�����rvG� 2750 Kelley Parkway Plan review fee: �
<br /> �'kESH�4' Orono, MN 55356 h�
<br /> Total Fee: �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> w: This application form must be completed in full and all required information must be submitted. �
<br /> v Incomplete applications will be returned. (Please print) �
<br /> y� GENERAL WFORMATION: "_
<br />"} Job Site Address: �� � � `� � ��
<br /> �.� �� 35 - ��� ����� - ��
<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 be �'�
<br />��'�� required unless applicant demonstrafes sufficient on-site parking is available. Non-permitted events wil!not be allowed.
<br /> ;�•'
<br /> ��-
<br /> ; ' CONTRACTOR/APPUCANT INFORMATION: . sy�
<br /> �:� Name: `�,�2� ��� .�� l� ' '�
<br /> State License# � {�'y Expiration Date: ,j 3� ° l (
<br /> Phone: 1- "3 -- 8Y v'Z office cell �
<br /> Mailing Address: �� (� L � Cit : �� ZIP: ,5�" j 3,
<br /> ��. Contact Person: � � _ Applicant is: ontr ctor..>/ Homeowner (Circle One)
<br />� Email and/or Fax: � ,,�,r;✓�; _ �`' i,ryc.6,�,,/ �,���"�yS /�C C'�S� �
<br /> ti�: �
<br /> ? PROPERTY OWNER INFORM ION: • �
<br /> Name: `
<br /> Phone (day): ' F - y _ (j� '
<br /> Address: „7 y5 Cit : �� �2,C; ZIP: �"j' j
<br /> ',�: Email and/or Fax p
<br /> �
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review&permits
<br /> ❑ Door(s) ❑ Remodel ❑Water Damage
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) ❑ Repair torm 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.orp
<br />�g°
<br /> Overall Project Description: ��i.— - � ,, V�vL�� ;
<br /> Estimated Construction Valuation of Project (ex ding land) $ , ���
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<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 public but can be given to the subject of the g
<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 su I the information, the a lication ma not be issued.
<br />�' :
<br />` � Applicant's Signature: �' � %(�G Date: � � � �
<br />���y ��
<br /> { Last Updated: 05-04-2009 `
<br /> i ��,� � � ��'
<br /> �s F )a r
<br /> i �r_ � t�
<br /> , s�........... ... . ��.:t�:.�,. , . .. . , � x, _..�._. � �.,,e_.a on.�.-,�.�. ,,,�... ���:<�*��.y�a
<br />
|