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<br /> City of Orono `�
<br /> Building Permit Application for Internal Work `�
<br />�'� �,
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<br /> 3� (windows, doors, siding, re-roof, etc.) „
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<br />� a MailingAddress: Permit number: .��/� -Q��� �:
<br /> �� �.,�,� PO Box 66 �
<br /> #_"; � ^ Q Crystal Bay, MN 55323-0066 Date received: �' (� /L� �
<br /> �
<br /> ��� �� Received b
<br /> .� � �,,��-���, s, � Street Address: � Y� ��
<br /> �'�,nL� 4 '% ���' 2750 Kelley Parkway Plan review fee: �
<br />' ' �kE5H04'� Orono, MN 55356 � �
<br /> � Total Fee: %�� �f L-�
<br />, F;� M a i n: 9 5 2-2 4 9-4 6 0 0 F a x: 9 5 2-2 4 9-4 6 1 6 w w w.c i.o r o n o.m n.u s ��� r � c/ ,,
<br /> r�' This application form must be completed in full and all required information must be submitted. ;�
<br /> �
<br />���: Incomplete applications will be returned. (Please print) �
<br />�°�` GENERAL INFORMATION: ":� �
<br />�� Job Site Address: < �u l C� ,�c Q�;,��z� LJ� �
<br />�,r� Will this be a Parade o f Homes, Remo d ers S howcase Home or o t her Disp lay Home? ❑ Yes �'No
<br /> �w.
<br /> , /f yes, a special event permit is requrred with Po/ice Department and City Council approval 60 days prior to the event. Shuttle bus service wi/l be
<br />'�'>> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br />;t,;:
<br />��" CONTRACTOR/APPLICANT INFORM 10�, �
<br /> Name: f�'������S F o-,vf-,��._i �
<br />�,,, State License# �v��O a�7 7 —� Expiration Date: �
<br /> Phone: 7i.,"3 --�-(�-7-`1 l�7(p (office) ��, > - �s� -��?Yj (cell) �
<br />�� �
<br />�- Mailing Address: �, S� c��.,�� Cit : �r ,,�,,,� ZIP: S '^3�-`"
<br /> Contact Person: �a-1. ;o,,� tz;,,. Applicant is: ontractor Homeowner
<br /> � (Circle One) �
<br /> `. Email and/or Fax: ;�..�, ;^-�;d�,.,�,�s f �5. 7(�- � �-(�7_ -
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<br /> PROPERTY OWNER INFORMATION:
<br /> � Name: �'c�, �`1PSl, 6es�.�✓
<br />�� Phone da
<br /> ( Y)� ���� - 33�-`fil��-
<br />�" Address: �-o i S'�,r
<br />,�;' 6 i�����-ac,�' li'�' Cit : C7�'crz.o zIP: 5 S 35" ,
<br />�a. Email and/or Fax
<br />+ :
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<br />`��' PROJECT INFORMATION:
<br />��: Type of Project: Any earth movement may require
<br />�� MCWD review 8�permits
<br />=;a ❑ Door(s) ❑ Remodel ❑Water Damage
<br /> Minnehaha Creek Watershed District(MCWD)
<br />�� ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br />�ka Deephaven, MN 55391 �3
<br />� ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br />�� Fax: 952-471-0682 �
<br />�'�` Re-roof
<br /> ❑ Fire Damage www.minnehahacreek.or
<br />'" Overall Pro ect Descri tion: � � � �
<br />��,� 1 p i �<<� �.�{ «�r �� -r�� ��.,S e T����:y � � -� c��t G�
<br />`�'-�' Estimated Construction Valuation of Project (excluding land) $ �� �-�
<br />�,,�..
<br />��,:; APPLICANT ACKNOWLEDGEMENT:
<br />��� • Agrees to provide all information required or requested by the Building Department;
<br />,�,,
<br />�;'.
<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 /> t 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 enerall cannot be iven to either the ublic or the sub ect of the data. Our �'
<br />,�` 9 Y 9� P 1
<br />�r` 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 refus�to-su I the information, the a lication ma not be issued.
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<br /> : ApplicanYs Signature: �--- - L----- Date: ��3��j U
<br /> ti;,�:;. -�.—,
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<br />�f Last Updated: 05-04-2009 �
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