|
� :
<br /> _ � �. ��r; ���-� ?. ,. ,,
<br />� �. . ., , 4 , ��� �t�C � 7` ��i
<br /> - City of Orono �� `�
<br /> k
<br /> �;_ , , ���
<br /> i:: Building Permit Application for Internal Work �' �s �'�`�`�
<br />��. (windows, doors, siding, re-roof, etc.) �
<br /> �
<br /> � x�
<br /> Mailing Address: -,
<br /> Permit number. �-/ ;-L? y
<br /> �` 4.,0.� PO Box 66
<br /> ��
<br /> � .� � Crystal Bay, MN 55323-0066 Date received: � �' /O ��
<br /> ��-
<br /> ��� �� '' Received b ��
<br />�°�' �a ��-��` �. � StreetAddress: � y� �
<br /> �r; `� 9� �,,.
<br /> k ; � � Gti 2750 Kelley Parkway ' Plan review fee:
<br /> � L�kESIi04'� Orono, MN 55356 �
<br /> Total Fee: r7f-, j f�� �
<br /> ' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �CJ l� � �
<br /> This application form must be completed in full and all required information must be submitted. '��
<br /> z Incomplete applications will be returned. (Please print) ��
<br /> �4�; GENERAL INFORMATION: / �
<br />�� Job Site Address: �7 v Shh� �a� c�/ �o p �
<br /> � Will this be a Parade of Homes, Remodel rs Showcase Home or other Display Home? ❑ Yes �No
<br />��' If es, a s ecial event ermit is re uired with Police De artment and Cit Council a
<br />�� Y P p q p y pproval 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 /> �
<br /> ' '' CONTRACTOR/APPLICANT INFORMATION:
<br /> {.'
<br /> y,. Name: l �n �L����on
<br /> `` State License# 3/ Expiration Date: 3�3/-�/a +
<br />��' ��
<br /> Phone: -c 7 - �� office cell =
<br /> Mailing Address: ��,.f�,�,�� �� ,��,_�,i,e �v 3 Cit :�l„e/r Jl..' ZIP� �S y Y
<br />�. Contact Person: r�,���s-�,�- Applicant is: Contractor / Homeowner (Circle One) �'
<br /> Email and/or Fax. '��..yys -G�ov
<br /> a
<br />, ,;r
<br /> a� �
<br /> PROPERTY OWNER INFORMATION:
<br />� Name: ,C�� �C.I�e.�IQ,c� �
<br /> ��• Phone (day): 'Ji'o3-1�7f-�'7ov �
<br /> ; Address: _/�?v 5�•.�ty�.,,, City:���1��a Z�P:ss.�y l ��
<br />�-' Email and/or Fax ^
<br /> �s:
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review&permits �
<br /> ❑ Door(s) ❑ Remodel ❑ Water Damage ��
<br /> �
<br /> r� �indow s Minnehaha Creek Watershed District(MCWD) ��
<br /> O ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br /> " Deephaven, MN 55391
<br />��. Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590 g
<br /> Fax: 952-471-0682
<br />�, [�e-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> z., Overall Project Description: ao�, ,a �� a-�'S ty�
<br /> � Estimated Construction Valuation o roject xcluding land) $ v voo• �� k�
<br /> i,?:
<br />��
<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; ;n
<br />,,; :k
<br /> F � • 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 />�u, purpose and intended use of this information is to annually update our records and records of other governmental agencies �
<br /> �i re uired b law. If ou refuse to su I the information,the a lication ma not be issued. �~
<br /> X.`,
<br /> f i'
<br /> a�'�
<br /> �:��.
<br /> ApplicanYs Signature: Date: �
<br /> � �
<br /> LastUpdated: 05-04-2009
<br /> �.'� � -� a �: r`�� t � ��4 �
<br />.a< ._�,�'.�� ._.. � . - ,..xt�. � .,..r...3.,,... ..''�.,ss.v_ rz,�,o , ._ra.:i'� <��iW.c.y a�.a;�'�.,�.m.�a.,r�_`-ai��s
<br />
|