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<br />��{ City of Orono � y�� �����
<br />�� �� �� Building Permit Application for Internal Work
<br />�,�
<br />�� (windows, doors, siding, re-roof, etc.)
<br />�,.
<br />��`u - Mailing Address: � ,��
<br /> Permit number:
<br />_.�,` Q�O�\ CrysBtal Bay, MN 55323-0066 Date received: � / / /�
<br /> 1.:. �M�,.-.
<br /> r= �� -�- Received b
<br /> � �:��;;,�, �, Street Address: Y�
<br />��; �'�,n ' � e'� �,ti�' 2750 Kelley Parkway Plan review fee:
<br />��;: r9kE5Ii04'� Orono, MN 55356 p�
<br />� Total Fee: �f �Cf� ��
<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: J�"� ��R_��_��,_e,��} �-��
<br />��{ Will this be a Parade of Homes, Remodelers SKowcase Home or other Display Home? ❑ Yes �No
<br />�<<; If yes, a special event permit is required with Police Department and City Council approvaf 60 days prior to the event. Shuftle bus service wiU be
<br />'`` required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br />�
<br />�;
<br /> ux_ CONTRACTOR/APPLICANT INFORMATION:
<br />��
<br /> Name:
<br />�� State License# Expiration Date:
<br />��� Phone: (office) (cell)
<br /> Mailing Address: Citv: ZIP:
<br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One)
<br /> t��,;� Email and/or Fax:
<br />��
<br />�� PROPERTY OWNER INFORMATION:
<br />� .' Name: ;�o pP.� L�/aWr�
<br /> +� Phone (daY): _�� y�i�, - Z��SD �,.,�.�n
<br /> ' Address: l�, 3s �����.900 �c) City:�y�.-�,4. ZIP� � � � ;
<br />� Email and/or Fax �' �
<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 ❑ Storm Damage 18202 Minnetonka Blvd
<br />�� Deephaven, MN 55391
<br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br />��' Fax: 952-471-0682
<br /> �i � Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br />�� Overall Project Description: -
<br />�� Estimated Construction Valuation of Project(excluding land) $ �,�
<br /> t.
<br />�`:�
<br /> E�� APPLICANT ACKNOWLEDGEMENT:
<br />�. �
<br />� • Agrees to provide all information required or requested by the Building Department;
<br />�i; • 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
<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 govemmental agencies
<br />, = re uired b law. If ou refuse to su I the information, the a lication ma not be issued. �
<br />�>,,
<br /> _._.s---
<br /> —_ — ��-T�_
<br /> � , ApplicanYs Signature: —— --� Date: s�f�/�p/O
<br />�:
<br /> �. Last Updated: 05-04-2009 _ ��
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