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City of Orono
<br /> Building Permit Application
<br /> /��\ MailiPO Bo�r66 � Permit number:
<br /> �,�V
<br /> �� � �� Crystal Bay, MN 55323-0066 Date received:
<br /> ���`�� �� StreetAddress: Received by:
<br /> � ���°��::� �;,
<br /> �' �� ��" ti � 2750 Kelle Parkwa
<br /> � � ��,. ��j Y Y Plan review fee:
<br /> L`�kEsxo4`'� 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 /> tncomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: �":>��i a0 ;����: � �cA
<br /> Will this be a Parade of Homes, Remodeler 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 wil!be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted evenfs will not be allowed.
<br /> CONTRACTOR I APPLICANT INFORMATION:
<br /> Name: 13iu„� M, i�S�� �.i2sl_; �ew,�c4c°�,��
<br /> State License# �a,G.�y 54 Expiration Date:
<br /> Phone: (� i� - iv7c - ��N 3 (office) (cell)
<br /> Mailing Address: �- , . ,p�, Cit : ZIP:
<br /> Contact Person: � �,,,,- M,'i t�s i�, Applicant is: Contractor / � meowner � �c���ie o�e�
<br /> _____
<br /> Email and/or Fax: �•,�,i1es �� (J i^c>-���., t_ c�.-�, � T u� �_ eo,� t,-u � +�,-- E� ��h � Gw-�
<br /> PROPERTY OWNER INFORMATION: w �''��,f� a� �y ��� ��+��
<br /> Name: ij i�.,� M;��Sk,
<br /> Phone (day): �v i� 4�70- � �N�
<br /> Address: 3 y �L ;B a� ,,d e �'�>�,c,C City: (�;o:-,c ZI P: .:5�S j'S(�,
<br /> Email and/or Fax ���• i�i K, �,� �,�,�,,, i- �;.,,,..,
<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 [X] Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description: �z�,,,�if? �,v�c� ;N,�i�r -{lcG� GG,�FG� �,�� K��-Cl�e�n 4�nCf ��c�l,G��y w�u�'f�; �a��
<br /> Estimated Construction Valuation of Project(excluding land) $ ���G p� - r,� �
<br /> APPLICANT 8� OWNER ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department,
<br /> • Certify that the information supplied is true and correct to the best of his/her knowledge. The applicant and owner recognize I
<br /> that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff
<br /> has no alternative but to reject it until it is complete.
<br /> • The Owner hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property by
<br /> City Staff, consultants or agents, for purposes of investigation of this request.
<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 su I the information,the a lication ma not be issued.
<br /> �'.�-�
<br /> ApplicanYs Signature: L- Date: �/�3�n �J
<br /> Owner's Signature: Date: a�c� 31 D�`
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