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<br /> a , - City of Orono � ,�_ � ��
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<br /> Building Permit Application for Internal Work ` � � �� �
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<br />� (windows, doors, siding, re-roof, etc.)
<br />�� Mailing Address:
<br /> Permit number:
<br /> 4v 0,� PO Box 66
<br /> � � � Crystal Bay, MN 55323-0066 Date received: �
<br /> ��;�._ �
<br /> a r�� E:�� s, Street Address: Received by:
<br /> ,, �'�,n � �'� �ti�' 2750 Kelley Parkway � Plan review fee: ��
<br /> t�ifEs�o�� 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 /> �;
<br />�F Job Site Address: ��`Z7oZ �,� -�,,r,,.,,,-�� ^ � k
<br />��y Will this be a Parade of Homes, Remodele s 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 unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ,��
<br />'�' CONTRACTOR/APPLICANT INFORMATIO • .�
<br /> N a me: ��l.t i c.��,�J�s f �����.-,� �
<br />��'; State License# ���v a--1 7 ' Expiration Date: �
<br /> Phone: �io 3 - tf a � �-`I!� �l� (office) 7[0 3 �8��-1�Y�-cell) `°
<br />` �r Mailing Address: S� �c� Q„ N Cit : �� � ZIP:S"���q `�— �'
<br />�; Contact Person: -� ,� ��,'�.., A licant is: trac / Homeowner �
<br /> pp (Circle One)
<br />�� Email and/or Fax: ic,�,�, �L,.L<<,Q���s�-P�us - �o-� �7(� 3 `���7-10-�/
<br />�•
<br />���' PROPERTY OWNER INFORMATION: ��
<br />��: Name: iG.�.av� �� �I
<br /> �:
<br /> Phone da A
<br /> n ( v)� `�S�� -�-f 7(,� — [o��(9 �
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<br /> Address: aa-t�� �u9���� Cit
<br /> ,�� ' �- Y� O(� � ZIP: �S-3S( �
<br />�, Email and/or Fax ,3,
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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 �
<br /> r^ Minnehaha Creek Watershed District(MCWD) ''°
<br /> FY^; ❑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 /> M Overall Project Description: j c�� �� �,��( �rz - �.�� e��v S'���,�� S �
<br /> Estimated Construction Valuation of Project(excluding land) $ ,3 s' 6tsp ��
<br /> �
<br /> APPLICANT ACKNOWLEDGEMENT: ��
<br /> �
<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 t u the information, the a lication ma not be issued. ��
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<br /> ApplicanYs Signature: Date: 9 1 / C� �
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<br /> r . Last Updated: 05-04-2009
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