|
1.` ;.",3, _ "
<br /> ¢-1
<br /> 1
<br /> � . Cit of r � � � � � �`���
<br />�:
<br /> t O on
<br /> o ,
<br /> Y
<br /> .
<br />�� Building Permit Application for Internal Work µ� � F
<br /> : y�
<br />��� (windows, doors, siding, re-roof, etc.) �
<br /> Mailing Address: �� _����. �
<br />`� �,L,0,� PO Box 66 Permit number. �
<br /> � ��� ` �
<br /> Crystal Bay, MN 55323-0066 Date received: �/ /D
<br /> . a � �-�;�, a, Street Address: Received by:
<br /> �'� � �� �,titi 2750 Kelley Parkway Plan review fee:
<br /> t9kESH0�'� Orono, MN 55356 �,
<br />* L Total Fee: / 9'�� �5 ��5
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br />` "E This application form must be completed in full and all required information must be submitted.
<br /> r_
<br />` °'' Incomplete applications will be returned. (Please print)
<br />��-:
<br />��: GENERAL INFORMATION: � ,
<br /> , �.
<br />�-�� Job Site Address: �f; ���: ; �✓�i; r�_ ( ; ;�r.r.��-- �����, ��� C��r;��:���,
<br />��s' Will this be a Parade of Homes, Remodelers Showcase Home or oth;�r Display Home? ❑ Yes No x�
<br /> If yes, a special event permit is required with Police Department and City Council approva�l 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 /> ���
<br />��{ CONTRACTOR/APPLICANT INFORMATION: �
<br /> Name: "
<br /> State License# Expiration Date:
<br />°'' Phone: _ (office) (cell)
<br />£` Mailing Address: _ City: ZIP:
<br />-f•� Contact Person: Applicant is: Contractor / Homeowner (Circle One)
<br />�z Email and/or Fax:
<br /> , ��; PROPERTY OWNER INFORMATION:
<br />�.
<br /> �
<br /> Name: ��,�y�1� .�i_fi����tl�1��r"�-
<br /> Phone (day): (�=7� � - ;�Co`') �
<br /> Address: ' ^ � �� �c� " � `� �
<br /> �f`_��f 5 :�o��;c e e i.L�c,.0 City: ��, � c� �.��; ZI P: ..� > j J 1 ;,,
<br />��'�; Email and/or Fax ��t l��, ,«.� � � ��,,,,,,, (� , �
<br />�!:.;
<br /> it4";
<br />�;:; PROJECT INFORMATION:
<br />� ` Type of Project: Any earth movement may require
<br />��,
<br />�' MCWD review&permits
<br />,�� ❑ Door(s) ❑ Remodel ❑Water Damage
<br /> Minnehaha Creek Watershed District(MCWD)
<br />„` ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> q 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 /> 4, �
<br /> Overall Project Description: r,�, �^,�c+
<br />' Estimated Construction Valuation of Project(excluding land) $ t(�, Q�.==� r
<br /> �
<br /> ��.
<br /> . �
<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 altemative
<br /> � 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 /> ' 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 />� PP 9 �- '%,' '� ��L'L,C_�� �;;%1� Date: / " r �f — �'� �
<br /> A licant's Si nature: �'"�'��
<br />��� �
<br /> ,� � �
<br /> Last Updated: 05-04-2009 v
<br />�
<br /> -a�.�rrN,,,�MvY'� ..; +af ,�a, y 'm
<br /> Rv
<br />��:�,� _ � �� ���x�,..��.�-.;I=.s'���,__ti ,.,. �..r� ..,..��' �'���
<br />
|