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<br /> City of Orono �
<br /> �
<br /> Building Permit Application for Internal Work .�
<br /> (windows, doors, siding, re-roof, etc.) �
<br /> Mailing Address: Permit number: �
<br /> g,0,�. PO Box 66 �
<br /> � � O Crystal Bay, MN 55323-0066 Date received: ;.
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<br /> ,� � G��z�, ,, Street Address: Received by: '�
<br /> �'.�, �� '�" �ti 2750 Kelley Parkway Plan review fee: 3
<br /> r9xE580¢'� 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�?v `'� n_`�c_� ���c".� ;
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o '�
<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 applicani demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �''
<br /> CONTRACTOR/APPLICANT INFORMATION: �
<br /> �
<br /> Name: � �IS� ��� �v/'���:.<�f � ;;n �
<br /> State License# �n�3 i 5 75 Expiration Date: 3-�/ - ;�-
<br /> Phone: �3 --y 7 7-�� ����=� office cell �
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<br /> Mailing Address: �-""i y5 ��S t,,;�i � , �ci Cit : ��,. � �J�,.. ZIP: S',;�3�� �
<br /> Contact Person N��,� �,�-��e�c Applicant is: n rac / Homeowner (CircleOne) �
<br /> Email and/or Fax: �s-� �j'?�� -[=r�,,�c, ,_,�;%� � ,� . , 1 !�v� �
<br /> PROPERTY OWNER INFORMATION: ,-, / , i
<br /> �
<br /> Name: ���� ��1 �- `�� ^;.�:� ;�v/�c.� ;�
<br /> Phone (day): l��- 3'.3 - ���3 �S `� ��
<br /> Address: i �Zc� �p��-�_ 'J 14c.� City: 1�'�a�s.{� ZIP:J -���
<br /> Email and/or Fax �
<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 �
<br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq �
<br /> Overall Project Description: �'�,,.,,� }��,�(c�� J) �1�,��
<br /> Estimated Construction Valuation of Project(excluding nd) $ �,�, vU���. �'"
<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 /> � ' �� � /
<br /> ApplicanYs Signature: �� �� G� L..__ Date: - � �( ��'��U
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<br /> Last Updated: 05-04-2009 �`
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