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City of Orono :�
<br /> , ;-• Building Permit Application for Internal Work ;�
<br /> (windows, doors, siding, re-roof, etc.) '_
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<br /> Mailing Address: � (-- 5� a
<br /> O�,�,�0 PO Box 66 Permit number: �;
<br /> Crystal Bay, MN 55323-0066 Date received: �
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<br /> ,� ��'� •, ,�+.,� s, Street Address: Received by: i
<br /> �'� '�� �ti�' 2750 Kelley Parkway Plan review fee: $'
<br /> t`�Esxoti`'� 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: C / �
<br /> Job Site Address: 38� �t��lS /3ti� �c� Q120i�(o I'�4� ,�S �S (o �
<br /> Will this be a Parade of Homes, Remodelers Showca e Home or other Display Home. ❑ Yes No �
<br /> If yes,a specia/event permit is required with Police Department and City Counci!approval 60 days prior to the event. Shuttle bus se ice will be �
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not 6e allowed.
<br /> CONTRACTOR/APPLICANT INFORMATIQN:
<br /> Name: � . ��, c(.,,_t l � (�, , �
<br /> State License# Z o � 3 � 5 � � Expiration Date: � 31 � -Z �
<br /> Lead Certification Number: Expiration Date: ,�
<br /> (for work on homes that were constructed piior to 1978 i
<br /> Phone: ��� , Z�� _ 7� c� 3 (office) q�Z - Y�( , 7 v S 9 (cell) �
<br /> Mailing Address: '��a� 5�,,�y� p ��,,,` City: 2;,� ��,,,��� ZIP: � � 3g `�
<br /> Contact Person: � , ,N,�S Applicant is: ontractor Homeowner �c�r�ie o�e� `�
<br /> Email andbr Fax: ��p�,,,,�}�� � �, c o,�.� ( y 5 2� �( '1 ( - 7� 5 `j +
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<br /> PROPERTY OWNER INFORMATION: `s
<br /> Name: ��� �y �`
<br /> Phone (day): Cq5 Z. y l� - o �'Z ;;
<br /> Address: 3 t35 S-�-..b bS �u^-� 12.c� City: ���o�y� ZIP: 5 S 3�(A �
<br /> Email and/or Fax �
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<br /> PROJECT INFORMATION: �
<br /> Type of Project: Any earth movement may require �
<br /> MCWD review&permits: �
<br /> ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) �
<br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Siding ❑ Restoration ❑ Other. (specify) Deephaven, MN 55391 �
<br /> Phone: 952-471-0590 >;+
<br /> �Re-roof ❑ Fire Damage Fax: 952-471-0682 `
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<br /> www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ � OQQ, 00
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> ;r
<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 appficant recognizes that they ��
<br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no atternative �
<br /> but to reject it until it is complete;
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<br /> • Some or all of the information that you are asked to provide on this application is classified by State taw 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 ss��
<br /> re uired b law. If ou refu to su I the information, the a lication ma not be issued. ;h
<br /> Applicant's Signature: � Date: �1� 1 �� �
<br /> Last Updated: 03-01-2011
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