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 /> g,0,� PO Box 66 <br /> 0 ;� � <br /> Crystal Bay, MN 55323-0066 Date received: <br /> I a�AY 1f I <br /> Received b <br /> I� � ����;�,�, �, i Street Address: Y� <br /> ���x���vG~/ 2750 Kelley Parkway Plan review fee: <br /> Esx / 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: ���,�� '�I�._��,� /�-<" /'�,�_„���;t <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No <br /> /f yes, a specia!event permit rs required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service wi//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: ,�>(,_ ���,�,.� ��(11� �--(Cl.i�'I ` i �LI S <br /> State License# ���, S�� ;� Expiration Date: <br /> Phone: ��2-�`10 313G (office) (cell) <br /> Mailing Address: � o� ,�n,,:�-r,i,�_ ��,,�. S< Cit : ,, �_J�` ZIP: �-5-3�i j <br /> Contact Person: �'�,�,��j�;,r�,s / T�S� !l y--� Applicant is: ontract��/ Homeowner (Circle One) <br /> Email and/or Fax: ' � - - <br /> -\�,.r✓.SC�cx,7rc4� ��l ,cc:-...� <br /> PROPERTY OWNER INFORMATION: <br /> � <br /> Name: �Lcl<�:�- (,J; (c��� <br /> Phone (day): <br /> Address: City: ZI P: <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) Q.Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> � <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 /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ �, ��, � .. LJ� ��^�� <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 governmentat agencies <br /> re uired b law. If ou refuse su I the information, the a lication ma not be issued. <br /> ApplicanYs Signature: � Date: C , � �`� <br /> , <br /> Last Updated: 05-04-200° <br />