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�, ' ' . .. '�� �;.' �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 />