Laserfiche WebLink
i <br /> it <br /> �Y�fO r _. City .of Orono <br /> Blv110ing Permit Application for Internal Work <br /> doors siding, re-roof, etc.) <br /> (windows, <br /> Mailing Address PiRrrrk rtumt�r <br /> PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date reoeived: • <br /> Street Address: <br /> .. 2750 Kelley Parkway Plan•reyiew fee:, <br /> Orono,MN 55356 <br /> Total Fee..'. <br /> m 952-249-4616, ww •ci.orono.mn us <br /> Main: 952 249.4600 Fax <br /> This application form must be completed In full and all required information must be submitted. <br /> 1 10'Incomplete applications will be returned. (Please piInt) <br /> 0E$rzRAL INFORMATION:', <br /> 35 1rQJJY__-6A)h Ad <br /> Job Site Address: <br /> WUJ#his•lie a Parade of Homes.Remodelers Showcase Home or other Display Home? Yes No' <br /> if yj,a special event penrlt is required with ponos Department and City Counal approval 60 days prior to the evdnt Shuft bus SWW=w0/be <br /> required unhSs,appGcpr�t clemonstraton suAklent on-sire policing is avauable. Aloe-pe►rnitted events will not be allowed <br /> tgt4TRACTOR I PPLI NT INFORMA N: <br /> Name: <br /> Expiration Dalte <br /> I�ad certification Numbe <br /> _. _ . Expiration Date:' <br /> - <br /> La R <br /> --(for work on homes t hat were consvncrw prior to 1978 (cell) <br /> Phone: - '1 3- -1 <br /> (office) <br /> � ,• City-. ZIP: •. q .. <br /> miling Address: al <br /> jCoritaet Person: Applicant is- on / Homeowner cam• )., <br /> Emall and/or Fax. - <br /> PROPERTY OWNER INFORMATION: <br /> �h <br /> Name':. <br /> da - , <br /> (day). l� QiCI. city; ZIP• 6cS)bE. u <br /> � ddmss: - <br /> Email and/or Fax _ <br /> PIO,ICT INF <br /> ORMATION: �`= <br /> TIS d��rolec>w,, � ,: Any earth movement may require <br /> MCWD"Mew&permits: <br /> ❑Door(s) ❑Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Repair ❑Storm Damage 18202 <br /> pM � ll <br /> Dh N5v <br /> Siding ❑Restoration ❑Other.(specify) Phone: 952-471.W90 <br /> ❑Re-roof ❑Fire Damage Fax 952.471-0662 <br /> .minneha <br /> Overall Project o"cription: 1( <br /> Estimated ConGtruetion Valuation of Project(excluding land) S , <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all Information required or requested by the Building Department; <br /> es <br /> • Certifithat the intbrmation supplied is true and correct to the best of histher 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 /> corrfiderrtial. 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 /> wired law. If u n3fuse to su I e information the application m not be issued. <br /> reqApplicant's Signature; %—JWDate: <br /> Last Updated: 03.012011 <br />