Laserfiche WebLink
� <br /> ,� � �, <br /> ity of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: c��'���� <br /> �v�,�j PO Box 66 <br /> �Q ,,\ Crystal Bay, MN 55323-0066 Date received: l 9 <br /> i �\� <br /> '' �� ��' Received b <br /> �� ��<;���,.�. �. Street Address: y: <br /> �'�n ���;��, Gti 2750 Kelley Parkway Plan review fee: <br /> t�kESH04'� Orono, MN 55356 � <br /> Total Fee: '7 ��'' �� <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: � f�. � ,/�� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes '� No <br /> If yes, a special event permit is required with Police Department and City Council approva160 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 /> Name: (�/�,�SL�.�_ �{¢��-�2-��w`h'�Pii, <br /> State License# aD�'3/�'�3 Expiration Date: �3 ?� -?oi� <br /> Phone: !la - 34(�- �2,83 (office) �3 - 4'3�-9.85s (cell) <br /> Mailing Address: g� ���( a /�- .� /o Cit : ,�/ �,�-{�� ZIP: SS <br /> Contact Person: Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: a.��/e,i- � �,e,,-,��� c�,,-� ��-����� <br /> PROPERTY OWNER INFORMATION: <br /> Name: (���,�- ,�(Q-��,� <br /> Phone (day): �,Sa" ��-_�gcl yY <br /> Address: c�o9 N �...�^ Q�� City: L0�„ti, ZIP� �3s� <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 /> ❑ 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 /> e-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: ,,e -� ,� _��� <br /> Estimated Construction Valuation of Project(excluding land) $ <j� �-� <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. <br /> ; � � � ,� <br /> ApplicanYs Signature: '� Date: �.� ,� <br /> ( <br /> Last Updated: 05-04-2009 <br />