|
-� �, : � s�r- s� • � �-
<br /> ' �� �� x'� , � ,�r
<br /> �" ��� ra�; � + Y ���r:
<br /> � .c�.tARS -.�N Ab. w. �F a. �•� �
<br /> . � City of Orono ���
<br /> � i�
<br /> Building Permit Application for Internal Work �
<br /> (windows, doors, siding, re-roof, etc.) ,;
<br /> �
<br /> ,. Mailing Address: Permit number. � �O—O� 7 �
<br /> 0 PO Box 66
<br /> � � Crystal Bay, MN 55323-0066 Date received: � oZ D :�
<br /> .
<br /> ��� �;_ � �� �
<br /> ��S'���>;_ �, i StreetAddress: Received by: �
<br /> : .� �
<br /> ' �'.�,L� � �,�� ��/ 2750 Kelley Parkway Plan review fee: iv � �
<br /> ��
<br />' ` `�kEsxo%� 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 /> �.. �;
<br /> x Incomplete applications will be returned. (Please print) �
<br /> � GENERAL INFORMATION: �
<br />�� Job Site Address: 'ZOC�t Su c�r�,.�oo �r��tc l_o �; MN �.�35C� �
<br />� ' Will this be a Parade of Homes, Remod rs Showcase Home or other Dis ay Home? ❑ Yes No �
<br /> /f es, a s ecial event ermit is re uired with Police De artment and Cit Council a �
<br />� y p p q p y pproval 60 days prior to the event. Shuttle bus service wil!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 />� � A�1�C5'C1 �C�G�.r
<br /> Name:
<br />��'y,„ State License# Expiration Date: �
<br />�Y,° Phone: �1 J2.. �Z�•�10\ (office) �6 .V1�3 � q `��i3 (ce��)
<br /> f- Mailing Address: r. Cit : �, �=
<br /> Contact Person: Applicant is: Contracto / omeowner (Circle One)
<br /> ° Email and/or Fax: (9(� ,� �
<br />��� �
<br />���; PROPERTY OWNER INFORMATION: �
<br /> t � Name: �GtX��C', Gt�g, kY1�K'
<br /> z�;� -
<br />� �� Phone (day): �
<br /> �
<br /> �.:
<br />���r Address: City: ZIP: �
<br />�� Email and/or Fax �
<br /> �
<br /> f �
<br />` PROJECT INFORMATION: �#
<br />��rt Type of Project: Any earth movement may require �
<br /> �; MCWD review&permits �
<br /> ' ❑ Door(s) �emodel ❑Water Damage �,
<br /> k:;
<br /> d;+
<br /> Minnehaha Creek Watershed District(MCWD) �
<br /> ❑ Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �'
<br /> Deephaven, MN 55391
<br /> �
<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:(�m������l,�X�'�l �
<br />� '` Estimated Construction Valuation of Project(excluding land) $ ?j�j (�'� �
<br /> � `
<br />�t �
<br /> �: APPLICANT ACKNOWLEDGEMENT: ��
<br />�$ • Agrees to provide all information required or requested by the Building Department; �9
<br /> 'l�.,
<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 /> rt..�
<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 />�l 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 /> a.�':
<br /> ,,
<br /> r-��
<br />���:„ �.
<br /> �� ApplicanYs Signature: �'��� Date: 5�24��� `�
<br /> �;�
<br />"`�� Last Updated: 05-04-2009 ,�
<br /> ��:, ��� `xi�. ' 4 �.
<br /> ,
<br /> , . .�,�...,.,.... .� .. ...., .>..,.� .. _.�r.s�.a��r:z;_ , _..�-.� .,�__.a�i-�.__�3V' i �.._ R.�,�a.;s i«. _+..,��. ,e�.i ,y,�
<br />
|