|
�, ' ' . .. '�� �;.' �Ys,:�.s � R"�+,T_ Y' v"�'.� M� ' R� �p
<br /> t.
<br /> ' . . , { � _ i � � j - _..
<br /> T . .. . . . . . . � � . . . _ . . � . . - � y }Y.
<br /> City of Orono �
<br /> x y ��Y ;k
<br />€r, � '� Building Permit Application for Internal Work � ' =
<br />��,, *
<br />_� ' (windows, doors, siding, re-roof, etc.)
<br />�� Mailing Address: Permit number: "�
<br />�, �.,�,j� PO Box 66 ��'
<br />� ', t-� Crystal Bay, MN 55323-0066 Date received:
<br /> X '; O "�^��3 1.. _ O �
<br /> a „���� �.-r-;� a, Street Address: Received by: ��
<br /> �'��%�� °�� 2750 Kelley Parkway Plan review fee: �;�:
<br /> 9kESHo¢'� Orono, MN 55356 ��
<br /> ��
<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: �
<br />�' Job Site Address: S
<br />�� �� 7�7/ i��i� �"�����, �� �
<br /> ��
<br />,� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No �
<br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service w 1 e �
<br /> ,'! required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. '�
<br /> CONTRACTOR/APPLICANT INFORMATION: �
<br /> �- Name: �-�1C 1��1\SL_ c�31�y�j ���Sc_S ��- �
<br /> '� State License# �
<br /> a�u)���t�,�l Expiration Date: // �
<br /> : Phone: �>� �� �_ � office C��,'�- S >� N '�� cell A��
<br /> a ' Mailing Address: ,,� )�� iY , )� Cit : �'� ,�d.;o,; ZIP: ��� � ) f�
<br /> � Contact Person: l��, _ Applicant is: ont ctor Homeowner
<br /> � , (Circle One) ��
<br /> " Email and/or Fax: �s�� y 7� - )� �-j
<br />�i �
<br /> F�-` PROPERTY OWNER INFORMATION: *�
<br />�"
<br /> � Name: .���;� O� ��
<br /> �
<br />�i Phone (daY)� '-�7��- ��`,'� � ��
<br />,;��; Address: Cit : ZIP:
<br /> ,. Email and/or Fax �
<br /> ..-
<br /> �
<br /> r� PROJECT INFORMATION: ��
<br />� Type of Project: Any earth movement may require �
<br /> �
<br />� _ �
<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 ��
<br /> Deephaven, MN 55391 �,�:
<br /> r, ❑ Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590 t�
<br />,,'�' Fax: 952-471-0682 �
<br />�;.� Re-roof ❑ Fire Damage www.minnehahacreek.orq �.
<br /> ��
<br />��- verall Project Description: � �- -x-- �`O� S � � �jyt �� �
<br /> Estimated Construction Valuation of Project(excluding land) $ / 9C% ;—
<br /> ��
<br /> ��
<br /> �' APPLICANT ACKNOWLEDGEMENT: �
<br />� Agrees to provide all information required or requested by the Building Department; �u
<br /> .
<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 altemative
<br /> but to reject it until it is complete;
<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 in rmation is annually date our records and records of other governmental agencies �
<br />�:: re uired b law. If ou refus to su the infor tion,the a lication ma not be issued. ��
<br />:i �s
<br /> '�;
<br /> �f �
<br /> Applicant's Signature: Date: � ���r� '
<br /> <.�
<br /> �E"C
<br /> � �
<br /> Last Updated: 05-04-2009 �
<br />�' � 7 �.�
<br /> _ ...._. _ _ ._ __ _... _�._.� ._ ..5��,��__s�:� ., . . . . ,.:��.�..
<br />
|