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<br /> t City of Orono
<br /> Building Permit Application for Internaf Work
<br /> (windows, doors, siding, re-roof, efic.)
<br /> Mailing Address �
<br /> ���,0�.� PO Box 66 Perrnit number: �(J �L�(�(p� 3
<br /> � ��\ Crysta]Bay, MN 55323-0066 Date received:
<br /> �� � �' s,j� Street Address: Rec,�ived by
<br /> �`\�'�, '����p� �� 2750 Kelley Parkway Pkan review fee:
<br /> �;� :`�11'�'
<br /> \�gEsi�o'�� Orano; MN 55356
<br /> `=--� Total Fee: l �D E ��
<br /> Main. 952-249-4600 Fax: 952-249-4616 www.ci.orona.mn.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> )ncomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: ���,�f
<br /> Job Site Address: .'y�.� �y`fri /`�''�G3 � �� ,> >
<br /> Wil!this be a Parade of Homes, Remode4ers Showca e Home or other Dispfay H me? ❑Yes
<br /> If yes,a specia/event permit is required with Police Departmenf and City Council approval 60 days prior to the event. Shuttle bus se�vice will be
<br /> �equrred unless applicant demonsbates su�cient on-site parkrng is available. Non-permitted events will not be allowed
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: !-r�i I i'�, `�`��r'v
<br /> State License# Expiration Date: �•-� f— �,C`
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes fhat were constr cted prior to 1978
<br /> Phone: ' — �j "[ - (office) � _- � /' ' ,� (cell)
<br /> Mailing Addrass: r` . �,,",,, .,� Cit • � �� ZIP:,�" `/
<br /> Contact Person: �, Applicant is: Contractor .,1 Homeowner �c��cie o�e�
<br /> Email and/or Fax: ; �,�,,d�'�w.� ,Es �;,.9z,,�,.;( � �'�,v,
<br /> PROPERTY OWNER INFaRMATION:
<br /> ,
<br /> Name: ��r� � i�,�'.
<br /> Phone (daY): �/�,�- 6�'�� 5�
<br /> Address: ����,r,,,� rF City_ ZIP:
<br /> Email and/or Fax
<br /> PRQJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑Remodel ❑Water Damage MCWD review 8�permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) []Repair rm Damage 18202 Minnetonka Blvd
<br /> ❑Siding ❑Restoration ❑ Other: (specify) Deephaven, MN 55391
<br /> Phone: 952�71-059a
<br /> e-r�of ❑ Fire Damage Fax: 952-471-0682
<br /> www.min n�hahacreek_orc
<br /> �verall Project Description: ;,� ` .G,�
<br /> Estimated Construction Valuation of Project(excluding land) $ , /�G
<br /> APPLICANT ACKNOWLEDGEMENT;
<br /> • Agrees to provide all inFormation required or requested by th2 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 n�alternative
<br /> but to reject it until it is compJete;
<br /> • 5ome or all o#the informaiion that you are asked to provide on this application is classifred by State faw 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 informafion 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..�o._�nnually update our records and records of other governmental agencies
<br /> re uired b law. lf ou refuse to su I the i rmation,�ie a lication ma not be issued_
<br /> Applicant's Signature: • ;j Date: ��
<br /> � /.�'= ,�cr r/
<br /> Last Updated: 03-01-2011
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