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<br /> t� � ' ' City of Orono �
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<br />�: Building Permit Application for Internal Work `` t,r�
<br />���� (windows, doors, siding, re-roof, etc.) ;�
<br />� Mailing Address: U �
<br />�" �,L,�,� PO Box 66 Permit number: a !U - 007 ,� �
<br /> Q r\ Q � Crystal Bay, MN 55323-0066 Date received: $ a � b
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<br /> a �' � �" �, Street Address: Received by: '`
<br />�'� , � s-_-� �,�
<br />�` �'� �A� Gti 2750 Kelley Parkway Plan review ee: '
<br />�.. '�9.kESHo4� Orono, MN 55356 � �
<br /> Total Fee.
<br />�° Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us S��• � �,�
<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: �/17 S� �r.�advc�S cfd" �
<br />�a Will this be a Parade of Homes, Remod ers 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 T�
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<br />�}_� required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br />�- CONTRACTOR/APPt�I ANT INFORM TION: �
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<br />��� Name: v't I 5�soa �«,oc(Q.lrn9 r1- S.��u-,�rs ��c
<br />�A: State License# d��q3�� Expiration Date: aor/ `�
<br />�� Phone: 6� office cell
<br />�� Mailing Address 7 y �,k t ,Uw Cit : ,.. � ZIP: �ty
<br /> �n�y Contact Person: /' �" A licant is: ontractor Homeowner
<br /> y, �vyL �jc�l�C p�e/" pp (Circle One)
<br />�;; Email and/or Fax: �,(J4llse4so�� co�cos��,v� 'f" �,�
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<br />�,~;; PROPERTY OWNER INFORMATION: `�
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<br />��:. Name: (1-e.o�q e /i'l� �eU hrP ;:
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<br />�'_� Phone (day): q5 a 4�6 c�SSy �
<br />� i. Address: o�./�c� Sv., ,-�a�s d'� Cit � d,2.o ZIP� ��:
<br /> Email and/or Fax ���
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<br /> k '� PROJECT INFORMATION: "�
<br /> , �
<br /> Type of Project: Any earth movement may require �
<br />�.�: MCWD review&permits �'�
<br /> ❑ Door(s) ❑ Remodel ❑Water Damage �'
<br />�°; Minnehaha Creek Watershed District(MCWD) ,��
<br /> ❑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 /> e-roof ❑ Fire Damage www.minnehahacreek.orq
<br />��` Overall Project Description: i'�
<br />�; Estimated Construction Valuation of Project(excluding land) $ y ��x� ,�
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<br />� APPLICANT ACKNOWLEDGEMENT:
<br />�.:
<br /> g ., • Agrees to provide all information required or requested by the Building Department; S�'
<br /> x,.
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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 ��
<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 informatio ,the a lication ma not be issued.
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<br />� ' Applicant's Signature: Date: g�3"`/C� ;
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<br /> Last Updated: 05-04-2009 '�:
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