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City of Orono
<br /> Building Permit Application for Internal Work
<br /> ' (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> O�,�,�.0 PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> � ��'���;� s, Streef Address: Received by:
<br /> �,c, " ° Gti�' 2750 Kelley Parkway Plan review fee:
<br /> ��k'Es80�`'� Orono, MN 55356
<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. (P/ease print)
<br /> GENERAL INFORMATION: '
<br /> Job Site Address: ���i ,���y�����j(' ��'���
<br /> Will this be a Parade of Homes Remodelers Showcase Home or other Display Home? ❑ Yes f`� No
<br /> lf 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 /> >
<br /> Name: �,;,.�;;�.,r�° �' �����a'�-� 'r'� �� ��c
<br /> State License# CG� I y� E piration Date: �'�, 3 �%
<br /> Phone: 7�-�, ��- yy$� office !��/� ) ��"- �:��='S cell
<br /> Mailing Address: �e 'ac Yzn e�,� Cit : ��� rrs ZIP: 5 S37
<br /> Contact Person: � �•%n o /`�; �,»�%(g Applicant is: ontractor / Homeowner (Circle One)
<br /> Email and/or Fax: r�,%,��`�j��p n'►r�p C a�15 �c"��dh. �o i�-� "
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ,��1� �'�:���a5
<br /> Phone (day): y :' . 5 y�� �, ;
<br /> Address: j¢,�,S 1��,y ,� �i� ��a� City: �� i: ,i� ZIP: g� ; y �
<br /> Email and/or Fax ,2,;�^, � L�.����,�f;".s, c�`.ti�
<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 /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Pro'ect Descri tion. � ' � '
<br /> J p , c>�. � k at;>f K�p144. � �::) �r;r�i'�%'�� , n ��r'�5'��r5 ��}�'�sa�n�i, ��z+r��� %,� �;ndc�v� ����yi�<°
<br /> Estimated Construction Valuation of Project(excluding land) $ �5, g'y(� �jJrs��ajS �h<% �ns. ��/ /5�
<br /> �.'ny o���
<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 /> re uired b law. If ou refuse to s. I the information,the a lication ma not be issued.
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<br /> ApplicanYs Signature: ; 4 ,�' <��L- Date: �: i` i�- � //
<br /> � r,��L �; <�
<br /> Last Updated: 05-04-2009
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