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<br /> Building Permit Application for Internal Work �:,
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<br /> (windows, doors, siding, re-roof, etc.) �
<br /> � Mailing Address: �/Y)Gj_ �� �
<br /> Permit number: �,�
<br /> ��v�,�`\� PO Box 66 � �
<br /> �Q Q\\ Crystal Bay, MN 55323-0066 Date received: 7 � Z�n!
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<br /> �,a �'�?��E�.� a�� Street Address: Received by: "' �'
<br /> � ��'.�, ' ti%� �ti i 2750 Kelley Parkway Plan review fee:
<br /> ��� '�9g��w Orono, MN 55356 ��
<br />,y�.,1 ESS�
<br />�•�: Total Fee: ��2 2,� "
<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 />�:` ,��
<br />-�. Job Site Address: 2Ly�-� S�w� y�a�,�_��_1'J��� ��� *
<br /> �=� Will this be a Parade of Homes, Remodelers Sh cow ase Home or other Display Home? ❑ Yes ❑ No ��
<br /> � lf yes, a specia!event permit is required with Police Department and City Counci/approva160 days prior to the event. Shuttle bus service will be ��
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permrtted events will not be allowed. e�
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<br /> CONTRACTOR/APPLICANT INFORMATION: � �
<br /> 1 Name: j ro.-�ecrr�l�, , f2i-f,�,�i� ,�� �
<br /> State License# �l ��1���� q/ Expiration Date: 7�,� -
<br /> Phone: y r?_?_�� ^'���� (office) (cell) �
<br /> Mailing Address: Cit : o(,�ns�n ZIP: G�� ;�'
<br /> ;,< Contact Person: Applicant is: ontractor � Homeowner (Circle One) ;�:
<br /> Email and/or Fax: C���1,,, i ��,o��,_ �qT�) �6� ��� � ,,,=� '
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<br /> PROPERTY OWNER INFORMATION: �';
<br /> Name: /�r�/� �-,�.,�-��' �.��ylt. �a6f�� � �
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<br /> Phone (day): �-rz - y �J ��1� � �-:
<br /> Address: �`
<br /> -2-t-��/�s,��/z�/wt-� /�� City: /}��va�r� ZIP: � 7 � �
<br /> Email and/or Fax �`�- �
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<br /> PROJECT INFORMATION: �`�
<br /> Type of Project: � Any earth movement may require
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<br /> MCWD review 8�permits ;�
<br /> t, ❑ 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 '
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<br /> Fax: 952-471-0682 �
<br /> ❑ Re-roof ❑ Fire Damage ,�� � �Q ;�,�
<br />' � � www.minnehahacreek.orq y
<br /> Overall Project Description: ��J I� ve�e�r �T�y^�- ,�,//�c ,r5 / ���_ �
<br /> '�`~ Estimated Construction Valuation of Project(excluding fand) $ �� �, �7—�
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<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 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; �
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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 /> purpose and intended use of this information is to annually update our records and records of other governmental agencies �;
<br /> re uired b law. If ou refuse to su I the information, the a lication ma not be issued.
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<br />�� ApplicanYs Signature: Date: � y zd�y �
<br />���� ��� � � �x
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<br />� : Lzst Updated: 05-04-2009
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