Laserfiche WebLink
Oct 0410 01:23p Michelle 612-208-1188 p.1 <br /> . . �.. <br /> City of Orano <br /> Building Permit Appiicati�n for Internai Work <br /> {windows, doars, siding, re-roof, etc.j <br /> Mailfig Address: Permit number: c20/D-O b 9' �� <br /> O.�„�„�O PO Box 66 <br /> C rystal Ba y, MN 35323-0088 Date received: � �� <br /> a� StreetAddress: Reoeived by: <br /> � �,� �' � 2T50 Kelley ParKway Plan review fee: <br /> ��,�$,�� Orono, MN 55356 <br /> 7ataf Fee: ���� �� <br /> Mai�: 952 249-4600 Fax 852-249-4616 ww�,v ci.orono.mn.us '[ <br /> This application form must be completed i�full and all required infarma6on must be submitted. <br /> Incomplete applicatians will be retumed. (Pfease print) <br /> GENERAL INFORMATION: �„3�� ���r �-: <br /> Job Slte Address: � <br /> V1rll this be a Parade of Homes, Remodelers Showcase Home or other Display� Home? ❑Y�s No <br /> lfye.s,a speclal event permit is►equhed with Pollce Department errd Ci(y Cour�u7 epprova!60 days piiarEc�e eve►rk Shu!(le bus sennc�e wr7!be <br /> required un/ess app►dcar�t demnnstrates�clenf on-s�parking is avar7sb/e. �fon-,pernrdted events wla nct be a/fowasd. <br /> CONTRACTOR 1 AP�P1LlCANT INFORMATION: <br /> kVame: TIDInn.��U1✓Z� I Y'►G • <br /> State License# �o S 53 0�a� �xpira6ari Date: <br /> Phone: 3-S l 8 ( office cell <br /> Mailing Address: a`I �n 6�, l.n. /IS Ci • or� ZIP: g' <br /> Contact Person: �'v(r �2. � Applicant is: ontracto Ha eowner cc�rcieo�� <br /> Email andlor Fax: <br /> PRCIPERTY OWNE�.�JFOI�MATION- <br /> Name: �SaY�>a�1� �c—TA�%��l <br /> Phone(day): q ,�2� '�I'7 3 - 59 <br /> Address: ���5 bbr S+ citv: ��d'1�,o z�p: u 5�3 <br /> Email and/or Fax <br /> PROJECT 1NFORMATtON: <br /> Type of ProJect Any earth movement may require <br /> MCWD revl�uv 8 permits <br /> ❑ Door(s) ❑ Remodel �Water Damage <br /> Minnehaha Creek Watersh�District(MCWD) <br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Mir�netonka Blvd <br /> Deephaven,MN 55391 <br /> ❑Si ' g ❑ Restoratiun ❑Other. (specify) Phone: �'i2-47�k-05� <br /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire Darnage wv�rw.mi�nehzhacreek.ora <br /> Overall Project Desc�iption: p � <br /> Estimated Construction Valuati�n of Project{excluding land) $ ��(� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all ir�formation requlr�ed or requested by tt�e Building Departrnent; <br /> • Certifies that the information suppli� is true and correct to the best of hislher knowledge. The applicarrt rec�gnizes that they <br /> are solely re.sponsible ior subm�ng a c�mplete applicatian being aware that upon fail�e to do so,the staff has no alfemative <br /> hut to reject it�mtil it is complete; <br /> • Some or all of the iniormatlon that you are asked to provide on this application is classified by 5tate law as either private or <br /> confidendal. Private data is ininrmation which generally cannot be given to the public but Can be given to t�e subject of the <br /> data. ConfcdeMial �ta is information vtifiich ge�erally cannot be given to either the public or the subject of the data. Gur <br /> purpose and irdended use af this information is to annually update our recards and records of other gwemmental agenCies <br /> r �ired b lew If ou refuse to su I the infa ation #he lication ma not be issued. <br /> Applicenfs Signature: Date: /� y r o <br /> Last Updated: Q5-04-2009 <br />