Laserfiche WebLink
_ � <br /> : � <br /> City of Orono � � <br /> ..: '+y 1'.4 �i <br /> ' 2 Y .' (� , .. <br /> - Building Permit Application for Internal Work = ��4 ; � <br /> . (windows, doors, siding, re-roof, etc.) <br /> ;� <br /> Mailing Address: Permit number: ' <br /> �v 0,� PO Box 66 � <br /> Q � � Crystal Bay, MN 55323-0066 Date received: �' <br /> � ,. <br /> ,,��;�- Received b "� <br /> a �� �',�, ..� a. Street Address: Y� <br /> �'� ���" �� 2750 Kelley Parkway Plan review fee: ,;� <br /> t�kESH��`'� Orono, MN 55356 �� <br /> Total Fee: }�' <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> �: <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 /> Job Site Address: ��� � � � , ���y, .�,�� �� <br /> Will this be a Parade of Homes, Remodelers Showca e 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/APPLIC T INFORMATION: ;�� <br /> Name: <br /> State License# �� � 5 Expiration Date: 3 �Z � <br /> Lead Certification Number. � f- Ex iration Date: � <br /> ���f � ��/ P �,� <br /> (for work on homes that were constructed prior to 19 8 �� <br />` �' Phone: - � -�c� - ��7C�; (office) (..��2 �-���-�� �3� (cell) �� <br />�� Mailing Address: �, �,,_.�`£% �,�. City: � � ,,,�ZIP: � <br />�, Contact Person: Applicant is: Contract r / Homeowner (Cirde One) � <br />� Email and/or Fax: �� <br />� <br /> . �� <br />` PROPERTY OWNER INFORMATION: , <br /> Name: j' ��-�`�� �i� �-c v`S � <br /> {�a <br /> �� <br /> Phone (day): �'�,5��._ - y.2(o - �D`tZ / � <br /> F ' Address: �c��'1 b�ti���..�,,-b2 �� CitY: ���' l� � .� <br /> Email and/or Fax � ZIP: fj��� � <br />. ���•: <br /> �.:, <br /> k. t�� <br />` ' PROJECT INFORMATION: � <br />�. i <br />� � Type of Project: Any earth movement may require f� <br />� '; � <br /> q•` ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: � <br />� Minnehaha Creek Watershed District (MCWD) '� <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ' <br /> ❑ S' ing ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 � <br /> Phone: 952-471-0590 <br /> 3-' Re-roof �� ❑ Fire Damage Fax: 952-471-0682 }" <br /> �� <br /> www.minnehahacreek.orq <br /> Overall Project Description: � <br /> , Estimated Construction Valuation of Project(excluding land) $ �� �i <br /> � � <br /> � <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 <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; f„ <br /> ca <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 }a <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our A; <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 information, the a lication ma not be issued. <br /> ApplicanYs Signature: %C.-- Date: 7 ZS � <br /> i`:, <br /> Last Updated: 03-01-2011 � <br /> �� <br />