Laserfiche WebLink
City of Orono <br /> � j ��' Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �-� Mailing Address: Permit number: p�/��� � <br /> O�v 0,� PO Box 66 <br /> O Crystal Bay, MN 55323-0066 Date received: � / <br /> I <br /> ���° � , <br /> Received b <br /> I a f�''� �F:.^% s, � Street Address: Y� <br /> ��'�,n � ' �'�' ti�' 2750 Kelle Parkwa <br /> Y� wG Orono, MNy55356 Y Plan review fee: <br /> `�kEssot� <br /> ` Total Fee: �a�� � � <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: <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 repuired with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> repuired unless applicant demonstrates sufficient on-site parking is avarlable. Non-permitted events will not be alfowed. <br /> CONTRACTOR/APPL NT INFOR�ATIQ1V: �s <br /> Name: �f3/Dv>" �Oc� i��' <br /> State License# _!y��� �"'� Expiration Date: ���� <br /> Lead Certification Number: � ;�- ;�_ L ,���s S�'//C��,7 L'�Expiration Date: <br /> 3 y-�s-�oil� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: �� � �,_ — (office) (cell) <br /> Mailing Address: 3 � � �c� City: ��,�? ZIP: s"sl�� <br /> Contact Person: � � - ����.f� Applicant i� Contr cto �/ Homeowner (Circle One) <br /> Email and/or Fax: _� � ��, , /-� , � �.. � ��� �i� C��i� � <br />� PROPERTY OWNER INFORMATI N: • <br /> Name: �i2� C�CIS'1����� <br /> Phone (day): �j' _ __ 3�� <br /> Address: � l <br /> e�� ��se /�r'(/z. City: ���,- �; ZIP: s� �/ / <br /> Email and/or Fax i <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 <br /> [�f2e-roof Phone: 952-471-0590 <br /> ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Pro'ect Descri tion: ��=�t,_�.�1 ;�.y,:-�,,, -� -� <br /> � p �� �/ 2- f% >C� vc<sy ;i,=�-�i�,�,,',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 I t inf atio�, e a lication ma not be issued. <br /> # Applicant's Signature: � '' / _ Date: ,j "o����� <br /> Last Updated: 03-01-2011 <br />