Laserfiche WebLink
2012-06-04 16:18 GRUSSING 9529356514 » +9522494616 P 2/3 <br /> � City of Orono <br /> �- � Building Permit Application for Internal Work <br /> { i (windows, doors, siding, re-roof, etc.) <br /> ,.��= -=_-. Mailirig Addness: Permit number. <br /> PO Box 86 <br /> Q� I �Q Crystsl Bay,MN 55323-0086 Date received: <br /> Reoeived : <br /> � Srreer Address: bY <br /> �► a� 2750 Kelley Parkway Plan review fee: <br /> '�4� � Orono.MN 553.5H a,aD <br /> -�_ _�.� <br /> Total Fee; <br /> � Main: 952-249-4600 Fax: 952-249-4816 www.ci.orono.mn.us <br /> j This application form must be completed in full and all required information must be submitted. <br /> � Incomplete applications will be returned. (P/ease prinf) <br /> GENER�L INFORMATION: a I I -� SI�GL� <br /> Job Site Address: j�J �}� �-�G� <br /> Wil!this be a Parade of Homes, Remodelers Sho se Home or other Display Home? Yes o <br /> If yas,s Ispecial eveni permit is reqaired with Polics peparbnent end C/ty Counci/epprowdl 60 deys prior to dhe event Shuttls bus xnxe i l be <br /> irequlned unleas applican!demonsbates sufHcJ�nt cn-sihe parklr►p is availab/e. No�ps►mitted events WIl1 Itot be aJ/owed, <br /> CONTRA�TOR/APPLIC NT INFORMATION: <br /> Name: I S� < • /4'r � y�'IC • <br /> State Lice�se# ' � Expiration Date: � �r y� (> <br /> Phone: I .S� - -v S 5 office ' � � (���7 y Y <br /> � (cell <br /> Mailing A�dress: .5 � Gi : '�yi�' ZIP: - �� <br /> Contact P�rson: . Applicant is: ra or / Homeowner �ci��a o�s� <br /> E m a i l a n d�o r F a x: S S�l i 7 YD v i I�! �C� <br /> I <br /> PROPER'�Y OWNER INF M TI N; <br /> Name, � � �D(rr1'G�Z <br /> Phone(da�): .S a — �-- �f.�-'7 .. . <br /> Address: � _ a I (� Sl� � t,�1v�-� Yl��'. Ci : I/v Z� Z1P: S��_ <br /> Email andl�r Fax _ � <br /> � � - <br /> PROJEC INFORMATION: <br /> Type of Prdject: �Any earth movement may require <br /> ❑Doo�(s) � ❑Remodel MCWD revie�w�permita <br /> ' ❑Water�amage <br /> ���o� Minnehaha Creek Watershed District{MCWD) <br /> ) []Repair ❑Storm Damage 16202 Minnetonka Blvd <br /> � Deephaven,MN 55391 <br /> ❑Siding � h�Q ❑Res[oration �]Other: (specify) Phone: 962-471-0590 <br /> a '"` <br /> Re-roof I ❑Fire�amage Fax: 952-471-0682 <br /> www.minnehahacreek.ora <br /> erall Prpject Description: � �vr,y� ��� ' 1 <br /> Estimated,Con� struction Valuabon of Pro�ect(excluding land) $ ��,�� <br /> APPLICA T ACKNOWLEDGEMENT: <br /> • AgrQes to prowde all�information required or requested by the Building Oepartment; <br /> • C ifies that the infoRnation supplied is true and carrect to the best of his/her knowledge. The applicant recognizes thai they <br /> are olaly responsible for submitGng a complete application being aware that upon failure to do so,the staff has no afternative <br /> but reject it until it is complete; <br /> • Sort�e or all of the i�ormation that you are asked to provide on ihis applicafion is Gassified by State law as either private or <br /> con dentiaf. Private data is information which generally cannot be given to the public but can be given to the subjed of the <br /> d Confidential data is information which generally cannot be given to either the public or the subjeU of the data. Our <br /> pu e and intended use of this information is bo annualfy update our records and records ot other governmerrtai agenaes I <br /> 'rod b law. If ou.refuse to supply the inrormation,th�application ma ny ot be issued. � <br /> ApplicanYs�ignature; pat�. f�/�/� �. <br /> � � � - <br /> 1 eef 1 I�A�IM• %1C 11� '�Ann <br />