Laserfiche WebLink
R / ' <br /> City of Orono �� <br /> ,'. <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: 6a <br /> O�,�,j�.O PO Box 66 Permit number. /d-�// � <br /> � <br /> Crystal Bay, MN 55323-0066 Date received: Oi / D ;s <br /> �;. <br /> � a �'���-%" �. Street Address: Received by: <br /> � � t <br /> �',�, � �ti 2750 Kelley ParkwaY Plan review fee: �� <br /> '�9���Yg� Orono, MN 55356 � <br /> ESH� � <br /> - Total Fee: ��j�. �j � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us `:' <br /> � <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: t�'.S C��=�t� �� (,� (J���-�� l'�,.J SS3� ' <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No � <br /> If yes, a special event permrt is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service ill be :� <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. k <br /> � <br /> CONTRACTOR/APPLICANT INFORMATION: � <br /> Name: ����-� Er�sk,-e ,��,���uel�Nq� s� � <br /> State License# �(j5,�.�LS� ` Expiration Date: � <br /> Phone: ��i�3- �S3— na� (office) "��3 �S�-�55�' (cell) <br /> Mailing Address: o �� ,:, �� Cit : -> �,,, ZIP: o/ � <br /> Contact Person: �s�� Applicant is: ontrac o / Homeowner �c��ae o�e� �� <br /> Email and/or Fax: ��� � l��-.'til,):LUM � <br /> '� <br /> PROPERTY OWNER INFORMATION: �: <br /> Name: L,��'��-- M+gG�l�k- 3 <br /> Phone (day): ���= ���-- o�-�i� <br /> Address: 'g'�S ., . �Q Cit : ����� ZIP: ,S.S35� .� <br /> Email and/or Fax — � <br /> � <br /> �; <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require � <br /> MCWD review 8�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 =r <br /> e-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: NC.�,� + �� <br /> Estimated Construction Valuation of Project(excluding land) $ a�c�ov <br /> APPLICANT ACKNOWLEDGEMENT: <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 /> 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 ' formation,the a lication ma not be issued. � <br /> �; <br /> � <br /> Applicant's Signature: Date: ��-�I I I� � <br /> � <br /> � <br /> LastUpdated: 05-04-2009 u <br /> � <br /> � <br />