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<br /> � City of Orono �`�� = i �
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<br /> Building Permit Application for Internal Work ���
<br /> �
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number: /D- D Dd X�
<br /> �,L,�,��\ PO Box 66
<br /> %� � Q Crystal Bay, MN 55323-0066 Date received: S/�
<br /> � � � �) � Received b � �'
<br /> '� ����'��-�;r �; Street Address: y �
<br /> " � �����'�,� o� 2750 Kelley Parkway Plan review fee: � ��
<br /> t;� �`�gESH�� Orono, MN 55356 �
<br /> - Total Fe : / � 3����� �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us j�
<br /> This application form must be completed in full and all required information mus e su mitte . v�
<br /> Incomplete applications will be returned. (Please print)
<br /> �
<br /> GENERAL INFORMATIOPL,: . � / ����, �
<br /> Job Site Address: �( �t") -� , f � �>�- (,�% � ;�,-- �
<br /> ( t c.,�� � ��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No `�
<br />+ lf yes, a specia!event permit is required with Police Department and City Councif approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ��
<br /> ��
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: ,�T���� c. >� �. i; ���
<br /> State License# � '�� (;, Expiration Date: � /�3
<br /> Phone: > , «-_ -- office �� ;�i S cell �
<br /> ; Mailing Address: ` � � T�. � t :, Cit � " � ' �� , ZIP� � � �
<br /> ' ` Contact Person: Applicant is: Contractor �:/ Homeowner �
<br /> (Circle One)
<br /> Email and/or Fax: - .�°� .
<br /> �r-� r r � ► �L„ L�?.•-` �
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<br /> PROPERTY OWNE INFOR TIO,�: �
<br /> ;� �
<br /> Name: ��1��.� �,K,J�.. I k=.�,5 ;�
<br /> Phone (day): � ���� �/L-� �� �;:
<br /> ,�ir', �C� S�/vw�- +t� �
<br /> Emdaeand/or Fax ��`' City�h"o��� ZIP� �S �� � �
<br /> _ �
<br /> PROJECT INFORMATION: y�
<br /> Type of Project: I Any earth movement may require �
<br /> �Doors MCWD review&permits
<br /> ( ) ❑ Remodel ❑Water Damage `�
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> �Window(s) `�Repair Storm Damage 18202 Minnetonka Blvd �
<br /> Deephaven, MN 55391 `'
<br /> '�'�liw��"�vc-�-�� ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682 L
<br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq "
<br /> �
<br /> Overall Project Description: � � � :7,� L, . L
<br /> Estimated Construction Valuation of Project (excluding land) $ , =--=- �3
<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 altemative
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<br /> but to reject it until it is complete; �
<br /> �
<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 /> �•
<br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies s��
<br /> re uired b law. If se to su I the inf ma n,the a licaf n ma not be issued. :�
<br /> �
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<br /> Applicant's Signature: Date: � j ��/O �
<br /> �
<br /> Last Updated: 05-04-2009 V� �.Q J`✓�� L � �`��'
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