|
"Y� �,'' � g' ,x" 'fi' .", '�y.�
<br /> . �� �k �i R : G���
<br />�' ` � �� ;� ? �"�A . , � .�3� .�,"..
<br /> i N�� y.��� �
<br /> w City of Orono � �����
<br /> �r�br�
<br />} , ���� ��
<br /> Building Permit Application for Internal Work - �
<br /> (windows, doors, siding, re-roof, etc.) �
<br /> �
<br /> Q� Mailing Address: Permit number: o�d -QQ �
<br /> �,� PO Box 66 /� �
<br /> Dj V� Crystal Bay, MN 55323-0066 Date received: �J /D � f�3
<br /> � ��
<br /> I.� �� ��-� �I Street Address: Received by: *`�
<br /> �' � 2750 Kelle Parkwa
<br /> �t�����, ��. Y Y Plan review fee: ��
<br /> �'kESH04�' Orono, MN 55356 � / ��
<br /> - Total Fee: � ��, L/� �
<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 /> Incom lete a li ��
<br />; p pp cations will be returned. (Please prmt) �
<br />� GENERAL INFORMATION: �
<br /> Job Site Address: ''Zv�'jv S �-io� ' �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home •r �ther �isplay H�me? ❑ Yes No
<br /> ,�:
<br /> If yes, a special event permif is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be ��
<br /> � r,„
<br />�;_,
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. w�'
<br /> `�
<br /> CONTRACTOR/APPLICANT INFORMATION: �
<br /> Name: �G,.11� (V1 L-M-� S-- �
<br /> State License# '20����;"3�� Expiration Date: 3•� I- Iv
<br /> Phone: _ 2- ��' - �j�; office cell
<br /> Mailing Address: y��3 S.4-c�� �„h;�� j Cit : ' c�- ZIP: 5 ,;
<br /> Contact Person: .,jG�.,..i �j (�,.v�v�iZ Applicant is: ontrac r / Homeowner (Circle One) '�
<br /> Email and/or Fax: ��c�,��,;,2 � ?-c�,�,�c,4 M,a A�r/�1F� cvM �
<br /> �
<br /> PROPERTY OWNER INFORMATION: �
<br /> Name: l�^� �i�r.��rfz�M .�
<br /> Phone (day): ��,� -�,�;7- 2�Q�
<br /> Address: 2c�Sc S�-{tii�c�r /'��Z - Cit : �A�Q�7,gT�} Z�P� `�
<br /> Email and/or Fax
<br /> �
<br /> �'.` PROJECT INFORMATION: �
<br /> Type of Project: Any earth movement may require �
<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 /> � Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682 �
<br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq '
<br /> �
<br /> Overall Project Description: �tna�y�- 5�a��,,,�, �,y�� ��,�.���,,z,�._�y�� f��j3`�,�
<br /> Estimated Construction Valuation of Project(excluding land) $ �S,OU(� �'
<br /> � �
<br /> APPLICANT ACKNOWLEDGEMENT: �
<br />,_;',
<br /> • Agrees to provide all information required or requested by the Building Department; �
<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; �
<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 /> �
<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 refus su I the information,the a lication ma not be issued.
<br />� ' _�
<br /> Q �
<br />���' Applicant's Signature: Date: U —1� " �� ��
<br />�,, �,
<br />"``' Last Updated: 05-04-2009 ��'
<br />;: 'r i" :4 � ,� -
<br /> , �
<br /> . . . < ,
<br /> ;
<br />�_. .. _.., _i: . . ,:� . �,r . a.: ,_ .,._.,r. _...�_ .. ,r_� . ,a ti.,_.. .,4,�� <_.
<br />
|