|
�. � r " � ,
<br /> A k:
<br />�� .. �� �y'�..
<br />�. City of Orono ; � .�
<br /> u. �, :�r
<br />�� ' Building Permit Application for Internal Work `� �`jt
<br /> (windows, doors, siding, re-roof, etc.)
<br /> �
<br /> �,
<br /> Mailing Address: Permit number: �
<br /> �v 0,� PO Box 66 �
<br /> Q � Q Crystal Bay, MN 55323-0066 Date received: �
<br /> ;• ��x a
<br /> ' ���� Received b '��
<br /> � d a ��.y� s. Street Address: y�
<br /> x'�nt � e° �ti�' 2750 Kelley Parkway Plan review fee: *
<br />�~. `�kEsxo4`'� Orono, MN 55356 ��
<br /> ,.7
<br /> ,,
<br /> Total Fee: a
<br />�� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �
<br /> 4 ; This application form must be completed in full and all required information must be submitted. `
<br /> s` Incomplete applications will be returned. (Please print) �
<br />�" GENERAL INFORMATION: �
<br />��' Job Site Address: 5� �} , S i i�f�(�.S ���( tZt� '�
<br /> r
<br />�=" Will this be a Parade of Homes, Remodelers 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 un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �
<br /> ���
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: /�13F3�t�T 2�s� ��.�r�'A� r'�
<br /> State License# y(Q ! Expiration Date: �'�
<br /> Phone: ��,2- �- �- y� � Z office) ��Z- -7f5-- 2735 (cell) :,�
<br /> Mailing Address: P � � — t �- 11� Cit � q ZIP: �
<br /> ; Contact Person: , )G_2�,�y ,� �l Applicant is. Contracto Homeowner (Circle One) �
<br />,,;, Email and/or Fax: �
<br />�", �
<br />��:, PROPERTY OWNER INFORMATION:
<br />�,, Name: (� ��ZT T wYL ,;;
<br /> �
<br /> Phone (day): (�t Z y��-oc��Co �
<br /> Address: 53 O I� . ST��p,s ga�y �2D Cit : Q�o C n ZIP� 5S 3�,(P ;:'
<br />�° Email and/or Fax
<br /> �a
<br /> PROJECT INFORMATION: ,�
<br /> k�_� Type of Project: Any earth movement may require '�"
<br /> MCWD review 8�permits r�
<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 /> ,s�
<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) $ �� dp� �'
<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 i�
<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 /> • 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 /> _ G� �
<br /> ApplicanYs Signature: �" � --� � Date: ( 7 /G „z
<br /> �P
<br /> ��
<br /> Last Updated: 05-04-2009
<br /> � �� �
<br />,.u, _ ,�._.__ � _. _ . , . ��.��.,;>is.a �.,��.�a���..,. _, , � e�s�:=�.�,�
<br />
|