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<br />� ���: City of Orono
<br />�� � Building Permit Application for Internal Work
<br />� .� , ,
<br />�}f (windows, doors, siding, re-roof, etc.) �
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<br />� Mailing Address: �
<br />�T �0,� PO Box 66 Permit number:
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<br />� ( 0 ,:\ Q Crystal Bay, MN 55323-0066 Date received:
<br /> � } + r � Received b �
<br />�' i� � ��� 4�+,� �, � Street Address: y�
<br />�� �� 6j� G��' 2750 Kelley Parkway Plan review fee:
<br />�� `�kEsxog'� Orono, MN 55356
<br /> Total Fee: �
<br />� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br />� `
<br />�' This application form must be completed in full and all required information must be submitted.
<br />�; Incomplete applications will be retu ned. (Pleas pri -
<br /> GENERAL INFORMATION: � �-
<br />�`` Job Site Address:
<br /> . ' /(/�Jc. ,� t
<br /> Will this be a Parade of Homes, Remodelers Showcase Ho or other Display Home? ❑ Yes ❑ No
<br />��` If yes, a specia/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 will not be allowed.
<br /> k�r�' ��
<br /> CONTRACTOR/APP�ANT IN�RMATIO�
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<br /> #F,
<br />��: Name: 1 a,v '� �hS,hC P�
<br />�'` State License# Expiration Date: �
<br /> Phone: _ ' - � office O cell '�
<br />�',, Mailing Address: - ���� ' � City: � ,i,y,,�0 ZIP:
<br />�' Contact Person: � c� A licant is: Contractor / Homeowner
<br /> pp (Circle One)
<br />�= Email and/or Fax: d o,i1 � �-r,�,�� � � ,� , L��,�,
<br />�� PROPERTY OWNER INFORMATION: ;��
<br />�.°r:: Name: " �O.� ` O S C�� a-
<br /> �" Phone (day):
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<br /> Address: Cit : ZIP:
<br /> Email and/or Fax � ��
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<br />�: PROJECT INFORMATION:
<br />��°��
<br /> Type of Project: Any earth movement may require
<br />�,� MCWD review 8� permits
<br />��-' ❑ Door(s) �emodel ❑Water Damage
<br /> �3
<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 k
<br /> �.
<br /> ,°: Fax: 952-471-0682
<br />�" ❑ Re-roof
<br /> ❑ Fire Damage www.minnehahacreek.orq
<br />��,;
<br /> a� Overall Project Description: � � � �
<br />��. Estimated Construction Valuation of roject(excluding la ) $ �
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<br />��} APPLICANT ACKNOWLEDGEMENT: �
<br />�;
<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 />�,.a 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 /> r, 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 r�f�se�fo�s'u information, the a lication ma not be issued.
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<br />�: � /
<br />�; ApplicanYs Signature: �• � Date: �
<br />�� � �
<br />�.� �
<br />�,.�� Last Updated: 05-04-2009 �
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