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<br />� � City of Orono ���� ��.
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<br /> Building Permit Application for Internal Work � �` `�
<br /> ��
<br /> (windows, doors, siding, re-roof, etc.) {�
<br />� Mailing Address: Permit number: ox�l�'dd�7 �
<br />� ��,� PO Box 66
<br />�; � � Q Crystal Bay, MN 55323-0066 Date received: l/(� �
<br /> ����.
<br /> ,;�� � � ��4�:^;e �, Street Address: Received by: �
<br /> �:; �'� ° '" Gti 2750 Kelley Parkway Plan review fee: ,� �
<br /> L`�kEsxog'� Orono, MN 55356 r�
<br /> - Total Fee: �Q � �� �
<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 INFORMATI N:
<br /> Job Site Address: �a� S' 2;, �.c� �;
<br /> Will this be a Parade of Homes, emo lers 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 will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> P�^.. �.
<br /> ip.;i.:
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<br />�.' CONTRACTOR/APPLICANT INFORMATION:
<br />��� � Name: Ll//s�� C��sC���f ��� �.�
<br /> State License# ��,�,31,s75 Expiration Date: 3-3/ - l..Z '''
<br /> Phone: �3 -y� . o„ office cell
<br /> Mailing Address: �/ � �,� f�;,J S�. `.,, � �v Cit : (� , �,;�, ZIP: � ' <<
<br /> xu Contact Person: N,�1� �r�.e.� Applicant is: / Homeowner (Circle One)
<br />-�°�'- Email and/or Fax: 7�3� c�-� y - �� 6�,
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<br />� PROPERTY OWNER INFORMATION: �"�
<br />��;:
<br />�7,_ Name: 4 �-� t�C� �! � �e� �,
<br /> �:
<br /> x�; Phone (day): -�, 3_ti ?�� -s z�� �,
<br /> Address: �,��//�� S"'p�,,.�� /� �� Cit :��c�,-�;, ZIP:
<br />�:` Email and/or Fax -�
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<br /> � PROJECT INFORMATION:
<br />� Type of Project:
<br /> Any earth movement may require �
<br /> MCWD review&permits �
<br />�; ❑ Door(s) ❑ Remodel ❑Water Damage
<br />��4�; 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 />�:,; e-roof ❑ Fire Damage www.minnehahacreek.orq '
<br />�`� Overall Project Description: e�; �,�..� r°�,� � ��`*�n,`� =
<br />� �
<br />��� Estimated Construction Valuation of Project(excluding land) $ 7 c a � ,�
<br />�>.:
<br /> � �
<br />�, APPLICANT ACKNOWLEDGEMENT: ,,�
<br />�,' • Agrees to provide all information required or requested by the Building Department; �^
<br /> �
<br /> ``�r • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they �
<br /> t:3r;} are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
<br />�'r;t, 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 /> �i 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 />��'�<5 re uired b law. If ou refuse o su I the � f rmation, the a lication ma not be issued.
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<br />� , ApplicanYs Signature: .� Date: Gu � ,5 O �'� G
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<br /> LastUpdated: 05-04-2009
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