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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 /> Mailrng Address: Permit number. �;
<br /> �,0,�. PO Box 66 ,
<br /> �� O Crystal Bay, MN 55323-0066 Date received: �
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<br /> a �'�'��" o-, � StreetAddress: Received by: �
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<br /> �'�,c, 4 B"� �ti 2750 Kelley Parkway Plan review fee:
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<br /> '���'� Orono, MN 55356 ,��
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<br /> Total Fee: j „(„ ` , � ''� ;
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �/lY �,�
<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: `
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<br /> Job Site Address: /�� ;�_(�,.t.-v� ���- . =
<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 demonstrates sufficient on-site parking is available. Non-permitted events wrll not be allowed.
<br /> CONTRACTOR/AP�CANT INFORMATION: �
<br /> Name: -r,t., ',c ti.z i-�G��-S �1� '�
<br /> State License# ���� J;�,r� Expiration Date: � ��j � �'
<br /> Phone: � �;) - ��� �- �;��' � office cell �
<br /> Mailing Address: ', (y h Cit : �i ��;y�ZIP: �„� �
<br /> Contact Person: ���,z..��y�L, Applicant is: ntrac or Homeowner (Circle One) -.
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<br /> Email and/or Fax:
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<br />' PROPERTY OWNER INFORMATION:
<br /> Name: �rviv�t /�{��z�%�'l-�.CcrYl
<br /> �:�� Phone (day): �3�� � G � � `'SS "'
<br /> Address: ;�,/_3 5 Sa�E.v,/l � City: �I�G✓t.0 ZIP:.���(� �"
<br /> Email and/or Fax �;
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<br /> PROJECT INFORMATION: ��
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<br />,`�: Type of Project: Any earth movement may require �
<br /> ' MCWD review&permits ,,�
<br /> ❑ Door(s) ❑ Remodel ❑Water Damage r '
<br />' Minnehaha Creek Watershed District(MCWD) s
<br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd F
<br /> Deephaven, MN 55391
<br /> ❑ Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590 "
<br /> Fax: 952-471-0682 ��
<br /> e-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overalt Project Description: � � �� � � ��� ��;
<br /> I,�C�{/ L� _ /�//ir>.�!�' C` �;
<br /> Estimated Construction Valuation of Projec ( xclu ' g land) $ y(� ����
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<br /> APPLICANT ACKNOWLEDGEMENT: �'�
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<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 /> y are solely responsible for submitting a complete application being aware that upon fail�re to do so, the staff has no alternative z�
<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 Y;
<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. '`
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<br />�,�, ApplicanYs Signature: � r;> Date: ,O� �'V��
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<br /> Last Updated: 05-04-2009
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