Laserfiche WebLink
City of Orono <br /> r Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) 2 <br /> Mailing Address: Permit number: 2-011-0 <br /> J(p <br /> O�0,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: ah t/ <br /> + ' ti Street Address: Received by: <br /> C 2750 Kelley Parkway Plan review fee- <br /> UO <br /> ESHOS`t� Orono, MN 55356 Q <br /> Total Fee: S.- <br /> 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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 7O(1 V wA tt 6 <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 /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: M1 6& .0 1O12 S /Y <br /> State License# Z051 SgOG, Expiration Date: 3 ZO/3 <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: _ 6I2_SW_29_0 6 (office) (cell) <br /> Mailing Address: (� �' �� City: 9 ZIP: 55,303 <br /> Contact Person: kkL6 'U11S'TE R y pE7" Applicant is: Con / Homeowner (Circle one) <br /> Email and/or Fax: U11LDE2fvf5� EXT NISI-LDS") <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: IC96NNAW.A- 12.D City: 69ON6 ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> XWindow(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> CP Siding ❑ Deephaven, MN 55391Restoration Other: (specify) Phone: 952-471-0590 <br /> [�Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.org <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ 16, 000 <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; <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 /> required by law. If you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: Date: S - /q-? ()j i <br /> Last Updated: 03-01-2011 <br />