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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.) ��
<br />� ~' Mailing Address: �j��U- �Z 7�
<br />��-�' �,� PO Box 66 Permit number.
<br /> r'� Crystal Bay, MN 55323-0066 Date received: ���/v
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<br /> =� j�� Received by: ,f�
<br /> � � � ��a;,_� a � Street Address:
<br />< i' �'�,c,� ° �'� �ti 2750 Kelley Parkway Plan review fee:
<br />`' " �xESH�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: , � �� � � , i�
<br /> Job Site Address:
<br /> Will this be a Parade of Homes, Remodelers Showcase Ho e 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 />�°` CONTRACTOR/APPLICANT INFQRM T�ON:
<br />�` Name: /�� i,'I � / �
<br /> State License# / Expiration Date: "� —
<br />� :' Phone: Q L off ce cell
<br /> i,.*��. y.'�-
<br /> ,, Mailing Address: Cit : ,/� ZIP: �
<br />�. Contact Person: Applicant is: ontract / Homeowner (Circle ne) �
<br />� Email and/or Fax: ��
<br />�;
<br /> PROPERTY OWNER INFORMATION: �
<br /> Name:
<br />�' Phone (day):
<br />�,;,'; Address: City: 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&permits �;�
<br /> ❑ Door(s) ❑ Remodel Water Damage �
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd a.
<br /> Deephaven, MN 55391 ;�
<br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682 ��
<br />�. ❑ Re-roof ❑ Fire D mage www.minnehaha ek.or „ �
<br /> '-� Overall Project Description: � �� ���
<br />��-
<br />�.;> Estimated Construction Valuation bf Project(excludin land $ V � '� v� < �
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<br /> � APPLICANT ACKNOWLEDGEMENT: �'�l l� � `"S���S �C ���
<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 /> .
<br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
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<br /> but to reject it until it is complete;
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<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 /> k� purpose and intended use of th� infor ation is to annually update our records and records of other governmental agencies �'�
<br />� re uired b law. If ou refuse t su I the in rmation,the a lication ma not be issued. �
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<br /> L :' ApplicanYs Signature: Date: �� �/� �'�
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<br /> 3 " Last Updated 05-04-2009
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