|
10/1 14:02 6514382901 CONNELLS CUSTOM EXTE PAGE 02/05
<br /> City of Orono
<br /> 6uilding Permit Application for Internal Work ,
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Meiling Address.. � � � , � �, . .'% - C:
<br /> .g,�,j�. PO Bax 66 P�Rnft�nu�nber�; • G,.�:i"r C "�`�C� ,
<br /> 0 0 a
<br /> Crystal Bay, MN 55323-0066 O�te;r�iv�d'<: :'��. ../ (�'':�1�%'
<br /> a, St�etAddress� Kek��tl"by: : ;� ,°,L;-
<br /> � >;;;,, , ,,;, ;, , �.,�-``' ,,�;,,; "..' �.
<br /> oti 2750 Kelley Parkway '�P�a�re�ieiwi����,: `� `;:;;:;,�,
<br /> ����g� Oronv, MN 55356 ��•-: '
<br /> 1 Tot�ti��t , ,` �,C,�i �� , ;'
<br /> Main: 952-248-4600 Fax: 952-249-4616 www.ci.orono.mn.us ;�i'� '�
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete application�will be return�d. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: ' 3�
<br /> Will this be a Parade of Homes, Remodelers Sho se Home or other Display Home? ❑ Yes No
<br /> If yes,a speciel event pennit is required with Pol/cA Department and City Counci!approval 80 deys prior to the event. Shutt/e bus sonrice will be
<br /> �equired�nless epplicent demonshates su�cient on�site petking is eveileble. Non-pem►itted ev�nts wil!not 6e ellowed.
<br /> CONTRACTOR 1 APPLICANT IN�ORMATION:
<br /> Name: � �.
<br /> State License# ��cc��,�— Expiration Date, � 2,
<br /> Phone: office � cell
<br /> Mailirtg Address: S, Ci : ZIP: 3
<br /> Contact Person: A plicant is: ontractor eowner �cir�io o�o�
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORMATION:
<br /> ►vame: �aA1fKA D' �'161,4.��
<br /> Phone(day): �52.-- �-1'l� bl p� � �j
<br /> Address' Ci : ��{,� ZIP: v��T�lo
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Projeat: Any earth movement m�y requir�e
<br /> MCWD review�permits
<br /> ❑Door(s) ❑ Remodal ❑Water Damage
<br /> Minnehaha Creek W9tershed District(MCWD)
<br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> (�5iding ❑ Restoretipn ❑ Other; (specify) Phone: 95z-471-0590
<br /> Lxr�e-roof Fax: 952-471-0682
<br /> ❑ Fire Demage www � ahacree .
<br /> �Overall Project Descr'iption: � � Q �� [�� ��_r�jq, � � �,
<br /> Estlmated Construction Valuation of Pro)ect(ex uding lan ) $ 1 b �� �- � ''�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agnees to provide all information required or requested by the Bullding Department;
<br /> • Certifies thet the information supplied is true and correct to the best of his/het knowledge. The applicant recognizes that thsy
<br /> are solely responsible for submitting a complet� application befng aware #hat upon failure to da so, the staff has no alternakive
<br /> but to rejed it until it is complete;
<br /> • Some o� all of the information that you are asked to provide on this application is classified by State law as sither private or
<br /> confidential. Private data is information whPch geRerally cennot be given to the public but can be givsn to the subject of the
<br /> data. Confidsntial data is information which generally cannot be given #o either the public or the subject of the data. Our
<br /> purpose and intended use of.this information is to annually update our rewrds and records of other governmental agencies
<br /> re uired b law. If ou refuse to su I #he information,the a lication ma not be issued.
<br /> Applicant's Signature: Date: ��gL� _./�
<br />
|