Laserfiche WebLink
� <br /> . City of Orono � <br /> � Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> 4v 0� PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: <br /> /O e,:� �\� <br /> `� ' � Received b <br /> a � ' �4�;;�. � StreetAddress: y� <br /> �'� " �`� �ti 2750 Kelley Parkway Plan review fee: <br /> ��kESH�4'� 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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �� �1 �z s Cv �� <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 Counci/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/AP IC NT IN OR ATION: n <br /> Name: ��'� �- ��� e��s c.�!-v�1i� <br /> State License# �Lz(, 3�'L 3n Expiration Date: 3 3� z�;� <br /> Phone: 7L" a7 �7�� (office cell <br /> Mailing Address: 3 �� �/2 �(,�,,,.� S Cit : ` � ZIP: �� <br /> Contact Person: � Applicant is:�ntractor Homeowner �c���ie o�e> <br /> Email and/or Fax: r�� ,� � .4E��,�� �,;,,,, <br /> PROPERTY OWN INFORMATION: <br /> Name: � .��-. ��;,��.��.-,h <br /> Phone (day): �l��-�7(-'"��i� <br /> Address: 3�7?�i �.s co N.�� Cit : ��,�, � ZIP: `li <br /> S� ^3 <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 /> Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> verall Project Description: <br /> _ Estimated Construction Valuation of Project(excluding land) $ ��� <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 su I the information,the a lication ma not be issued. <br /> 7 / <br /> Applicant's Signature: Date: � �P ��d <br /> Last Updated: 05-04-2009 <br />