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<br /> � �• City of Orono ���t
<br /> ,
<br /> Building Permit Application for Internal Work �
<br />� (windows, doors, siding, re-roof, etc.) �
<br />�: ,�..
<br /> : Mailing Address: �
<br /> 1�
<br /> O�v�,� PO Box 66 Permit number: C,/6- �
<br /> 0 Crystal Bay, MN 55323-0066 Date received: Z, �
<br /> `' �`,
<br />"` ' a �`���,������ a Street Address: Received by: �
<br />��4 �'��9 ����� 2750 Kelley Parkway '� Plan review fee:
<br /> �,�
<br /> kESSO4' Orono, MN 55356
<br />�,=F; — Total Fee: � �'f ` �� �
<br /> a;..�. 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. (P/ease print)
<br />�{v GENERAL INFORMATION: �
<br />��' Job Site Address: 2( �N Suq a� �„�000qS ���. ��
<br /> Will this be a Parade of Homes, Remodelers 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 /> F . .
<br /> A;; required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �:,
<br />�.,
<br /> ' CONTRACTOR/APPLICANT INF RMATION: �`
<br /> ��'
<br /> �, Name: N1�d���S� o �1 � S' d�(�r, ��.
<br />��` State License# �� �
<br />�r va a 27 Expiration Date: Z '
<br />�, ° Phone: � z. 7 � 5 office cell `
<br />� Mailing Address: u s GG o�c G� • Cit : ( , IP: SS'
<br /> a
<br />�,:: Contact Person: Applicant is: ntrac / Homeowner (Circle One) �
<br /> i Email and/or Fax: �
<br />�u.
<br />�; PROPERTY OWNER INFORMATION: �
<br />�`� Name: (,�r
<br /> 5 n' �o�n
<br />�.1 Phone (day): � � 2,
<br />�'" Address: � i vv�, �S O r Cit : ZIP: �.
<br />�" Email and/or Fax �
<br />�`:
<br />�. PROJECT INFORMATION:
<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 />�' ' ❑ Sidin
<br /> g ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 '
<br />�`'' Fax: 952-471-0682
<br />'#' - of
<br />��,r ❑ Fire Damage www.minnehahacreek.orq
<br />� Overall Project Description: '
<br />� ; _Estimated Construction Valuation of Project(excluding land) $ - (�! �p d, D d �
<br /> �
<br />����; APPLICANT ACKNOWLEDGEMENT: �
<br />���` • Agrees to provide all information required or requested by the Building Department;
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<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 />�"; �
<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 />�k° 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 information,the a lication ma not be issued. �
<br /> �_:.
<br /> �
<br /> �`
<br /> f ` ApplicanYs Signature: '���/ �`- Date: � F z�o ,��'
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<br />�, Last Updated: 05-04-2009 �
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