|
• City of Orono 0-1 ss
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> �,0� Cr Bax 66
<br /> c ---?:(3,4?-�\` Crystal Bay, MN 55323-0066 Date received:
<br /> 1 '",.i-.,c,'- s, Street Address: Received by:
<br /> .,4. �i0,tj Gti
<br /> `�kEsso4`' 2750 Kelley Parkway
<br /> Orono, MN 55356 Plan review fee:
<br /> Total Fee:
<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: ,7--,r:9( (4Leoc y- 7SA.,2 .e,'�, / e
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes R"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/APP ANT INFORMATION:
<br /> Name: a lr<'-7 ,( C a-c-tc%7,'>-, C-ors4--, 6.w� z.,-.c
<br /> State License# . as 5'2 .7-95 Expiration Date: Z31/.0_01,z.--
<br /> Phone:
<br /> 3//�0 LPhone: (2r 2 -7 5 b -3 S 4 O (office) Qj5o -Y-gb=-.5-0 os ^ (`7sSS y) (cell)
<br /> Mailing Address: /6 z(f` Lei,jl _,(rrc City: ZIP:
<br /> Contact Person: _ , ,`;-, Applicant is. .. ontracoi) / Homeowner (Circle One)
<br /> Email and/or Fax: Loll/'vt ol-? f`hN c tc-.'c,.. 6J y-;,� ,�G-i2Q..4.-.4.70 .
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: y-c(« //'74;fr I tiN- l'`,“- s "r Pi
<br /> (
<br /> Phone (day): , (2- 1(37-rz2
<br /> s
<br /> Address: '2 $ -v f,,,pit - City:()(-01,-,_6, ZIP: S 3 56
<br /> Email and/or Fax
<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 /> AWindow(s) aAr Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> S+dirtg ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> E Re-roof ❑ Fire Damage www.minnehahacreek.org
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ (C0 c '7(.:_-) C.-,
<br /> /
<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: `A.,._.. Date: 7- 1 Z U
<br /> Last Updated: 05-04-2009
<br />
|