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<br />����; City of Orono � j : ��
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<br />�, t ' Building Permit Application for Internal Work � +� � �
<br /> i'` (windows, doors, siding, re-roof, etc.) ��'
<br />�"; Mailing Address: Permit number: j
<br />��� � �v�,� PO Box 66 �
<br />� ' 0 � 0
<br /> Crystal Bay, MN 55323-0066 Date received: �
<br />� • a ��`��� Received b
<br /> � G-r���. �, Street Address: y� �
<br />�; �'� ��" �,� 2750 Kelley Parkway Plan review fee: �
<br />�' t`�kEsxo4`'� Orono, MN 55356 e�r'
<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. (P/ease print) �
<br /> q��� GENERAL INFORMATION: ;� � �
<br />.�: Job Site Address: ��O ��.��/ � � - � ��,,��
<br /> � �.��u�i i �
<br />�� Will this be a Parade of Homes, Remodelers S wcase Home or other isplay Home? ❑ Yes ❑ No
<br />� Y P P q P y pproval 60 days prior to the event. Shuttle bus service will be �
<br /> ,g� If es, a s ecial event ermit is re uired with Police De artment and Cit Council a
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ��
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<br />��� CONTRACTOR/APPLICANT INFORMATION: k:�'
<br />��;�� Name:
<br />��;' State License# Expiration Date: �,.
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<br />�fi: Phone: (office) (cell �:,
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<br />��. Mailing Address: City: ZIP: �
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<br />�° Contact Person: Applicant is: Contractor / Homeowner (Circle One) �
<br />��: Email and/or Fax: ��
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<br /> r '` PROPERTY OWNER INFORMATION: ��
<br />�;; Name: �eff c;,�,�.so/� ��
<br />�� Phone (day): y��-���. ���� I `�
<br /> Address: �� c� �/ �a�,� � � �
<br /> r� Cit : C�i-��I� ZIP: �f_.57� �
<br />'��V� Email and/or Fax ff o�c ; ;K .�c� f
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<br /> PROJECT INFORMATION:
<br /> R Type of Project: Any earth movement may require
<br />'� ' MCWD review&permits
<br />��; ❑ Door(s) �Remodel ,�Water Damage
<br />� : Minnehaha Creek Watershed District(MCWD) w
<br />�,-� ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ;�
<br /> Deephaven, MN 55391 ; '
<br />�' �Sidin Restoration �
<br />�,• g ❑ ❑ Other. (specify) Phone: 952-471-0590 �T
<br />�� Fax: 952-471-0682
<br />�s ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ ;33CJ '::
<br /> ��
<br /> APPLICANT ACKNOWLEDGEMENT: ��
<br /> ` • Agrees to provide all information required or requested by the Building Department; �
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<br /> Certifies that the information su lied is true and correct to the best of his/her knowled e. The a licant reco nizes that the 'Y�
<br /> b`' • pp 9 PP 9 Y �
<br /> s � are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
<br /> �
<br /> ; but to reject it until it is complete;
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<br /> x:, • 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 governmental agencies
<br />:'�n re uired b law. If ou refuse to su I th information, the lication ma not be issued.
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<br /> ApplicanYs Signature: ' Date: � ��
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<br /> Last Updated: 05-04-2009 n1 ,�,
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