|
�'
<br />; ,•�
<br /> �
<br />� City of Orono _ �. � �-' - ,8b�� i
<br /> � f ^
<br /> � r ' Building Permit Application for Internal Work �
<br /> (windows, doors, siding, re-roof, etc.) �2 �Y� �
<br /> ��
<br /> Mailing Address: Permit number: �
<br /> �,L�� PO Box 66 �
<br /> �
<br /> Q �\ �0�1 Crystal Bay, MN 55323-0066 Date received: 5
<br /> � t�' '���-`�' s.�� StreetAddress: Received by: �
<br /> � �,�:��� ,
<br /> �� " � � 2750 Kelle Parkwa �
<br /> � y y Plan review fee:
<br /> L�kESH04�' Orono, MN 55356
<br /> Total Fee: �
<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 INFORMATION: �
<br /> Job Site Address: ' � J r,� l " I �
<br /> �
<br /> Will this be a Parade of Homes, Rem de s Showcase Home or other Display Home? ❑ Yes No �
<br /> /f yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shu(tle bus service will be �
<br /> require d un less app licant demonstrates sufficienf on-site parking is available. Non-permitted events will not be allowed. '-c
<br />:� : ��a�
<br /> CONTRACTOR/AP LICA T INFORMATIO�: ��
<br /> Name: Go.,�
<br /> State License# � Expiration Date: ' Q 2 �
<br /> Phone: j, c�/- � office � - -, cell
<br /> Mailing Address: �' " - ,, ; j� Cit : -� , ZIP: � p;�
<br />�,�` Contact Person: ;� � � �.` Applicant is: Con rac or Homeowner (Circle One) s<i
<br /> Email and/or Fax: ru� t ? _ ' „ , r , ' ,,,.,
<br /> n,
<br /> PROPERTY OWNE I F RMATION:
<br /> Name: c- c�- � , � : r p.�
<br /> Phone (day): - -y7 - �
<br /> �.
<br /> Address: ^� Cit : �� ZIP:
<br /> ;; Email and/or Fax
<br />�w�::�'=
<br />��� PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review 8�permits $
<br />�- ❑ Door(s) ❑ Remodel ❑Water Damage �
<br /> ❑Window(s) ❑ Re air Minnehaha Creek Watershed District(MCWD) �
<br /> p ❑ Storm Damage 18202 Minnetonka Blvd �
<br /> � ❑ Sidin Deephaven, MN 55391
<br /> 4,; g ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> �
<br /> ,�Re-roof Fax: 952-471-0682
<br /> ❑ Fire Damage www.minnehahacreek.orq �
<br />�,;:: Overall Project Description:
<br />�� Estimated Construction Valuation of Project (excluding land) $ ,�
<br /> b:
<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 the information,the a lication ma not be issued.
<br /> ApplicanYs Signature: -`" Date: ��S��lT
<br /> LastUpdated: 05-04-2009
<br />� , �_ � .. •� " " '� k . T,¢P`,
<br /> r 'b
<br /> � .
<br /> 2
<br /> . ..... _.... ..... ... . ..... . ...... .. ...... . . ,..: .,,_... ,._:.n_, ...,: „ ..x �;. �� . . '�... ..,..1tAt`tw�.. c+- .!�_ <: .n � f,k.'� �
<br />
|