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<br /> City of Orono r��.. �� �
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<br /> � Building Permit Application for Internal Work - �a�
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<br /> (windows, doors, siding, re-roof, etc.) }�
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<br /> Mailing Address: �
<br /> Permit number:
<br /> �yv�,� PO Box 66 �,
<br /> � Q Crystal Bay, MN 55323-0066 Date received: �,
<br /> * �.
<br /> a � ���;�, s. f Street Address: Received by: ��
<br /> �' '� �"•' G�ti 2750 Kelley Parkway Plan review fee: �
<br /> �
<br /> ��kESHOg'� Orono, MN 55356 <;
<br /> Total Fee: �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ;.:�:
<br /> d ! This application form must be completed in full and all required information must be submitted. �'
<br /> f . Incomplete applications will be returned. (Please print) �
<br /> GENERAL INFORMATION: � ��?
<br /> Job Site Address: �����'.. � '�, _�, ,, ' � ),�-,,,� �'
<br /> �•, , , . , • , . / J� ��
<br /> Will this be a Parade of Homes, Remod'elers 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. :�
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<br /> CONTRACTOR/APPLICANT INFORMATION: >;,o
<br /> Name: /1//��:�,� �:�;��f.u`�� ,,;� '"'
<br /> State License# aoc,3,��s Expiration Date: -; -3�- � � �
<br /> Phone: 7�,3-ci �t -Fr�Jo (office) (cell) , r��t
<br /> Mailing Address: _��iys T,...,�,w.��,,..,•P� s L. 5�.�� ��,� City: �-r,�<< �-3;,;., ZIP. �_�� � ' i�
<br /> Contact Person: %/,���,� Applicant is: Contractor / Homeowner �c���ie o�e� '=�
<br /> Email and/or Fax: ��, 3 _ �a�;• -����� �
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<br /> „ PROPERTY OWNER INFORMATION: �.
<br /> Name: ^�::�.�, '>�Sci��w�- lC ��;
<br /> Phone (day): ��S� - y � ,�-�� ,� �
<br /> Address: �T , .�j ��-titi a�w��,,.l L�,-z Cit : /'��n o ZI P: ���5(, �
<br /> Email and/or Fax -� �
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<br /> PROJECT INFORMATION: ��
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<br /> � Type of Project: Any earth movement may require `
<br />,� � MCWD review&permits °
<br /> ❑ Door(s) ❑ Remodel ❑Water Damage
<br /> �k
<br /> Minnehaha Creek Watershed District(MCWD) s
<br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd s;
<br /> Deephaven, MN 55391 ��
<br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 �:
<br /> Fax: 952-471-0682 '
<br /> �e-roof ❑ Fire Damage www.minnehahacreek.orq �
<br /> Overall Project Description: T�,,� ,�f - , � � ,�, �/ �''/�,� /„�/ 3�, i,� ,r�f �:
<br /> Estimated Construction Valuation of Project(excluding land) $ ,�V vov. "" �
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<br /> APPLICANT ACKNOWLEDGEMENT: '`� ��
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<br /> • Agrees to provide all information required or requested by the Building Department; ::,�
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<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they �
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<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; �
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<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 inf rmation, the a lication ma not be issued. F�
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<br /> Applicant's Signature: � �� �. 1�,�--- Date:
<br /> Last Updated: 05-04-2009
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