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. + � City of Orono
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> MailingAddress: Permit number: -���`U�/b 7
<br /> �,�,�. PO Box 66
<br /> Q � O Crystal Bay, MN 55323-0066 Date received: / /O /C�
<br /> �,A�"�ti Received by:
<br /> a � � � ;�� s, Street Address:
<br /> �',�, 6 �ti 2750 Kelley Parkway Plan review fee:
<br /> t�,kESHp�¢,�' 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: .��� Gl-.�����, �,.�
<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 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 /> Name: ��,w-�� ��� �,,-�.�, (��-
<br /> State License# � <�� Expiration Date:
<br /> Phone: �,��-�g� -,�.� (office) (cell)
<br /> Mailing Address: ��� � c�,y,,,��,�,ti�._ t'�.� ��L��; City: ��, ��r,..\ ZIP: ��j(�;
<br /> Contact Person: ,j,,,,,� �„��,�,� Applicant is: actor / Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWN R INFORMATION:
<br /> Name: ��� � I"�a,,.. lc_.�Lc�„-
<br /> Phone (day): ��'Z_Z C�.�-Z,�..,;,
<br /> -�--
<br /> Address: '�g,f;3 ��.,_r,,� (�,,� City: C;�r„��� ZIP: `�� '��r
<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 /> OverallProjectDescription: '��,,,, -�;E'(�,- �-�-,r.�,(�
<br /> Estimated Construction Valuation of Project(excluding land) $ ��; �Z�;�"
<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 /> ApplicanYs Signature: Date: L �- ��� � �
<br /> Last Updated: 05-04-2009
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