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' City of Orono � ° ���"'
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> ��,� PO Box 66
<br /> 0 � 0 Crystal Bay, MN 55323-0066 Date received:
<br /> �".+.;,ar..
<br /> a ��.,���'�,'� s, SfreetAddress: Received by:
<br /> ti �
<br /> �'�n � ���� ti 2750 Kelle Parkwa
<br /> o y Y Plan review fee:
<br /> �`�kEsxo4`'� 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: 3a0S �'2�sCo l „L3,�,, ,ee�
<br /> Will this be a Parade of Homes, Rem delers Sho case Home or other Display Home? ❑ Yes ❑ No
<br /> If yes, a special event permit is required with Police Department and City Council approva!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: .4��s�A� C�,,rE,�.�Gt,..,,
<br /> State License# �o� 3 i 5 �S Expiration Date: �-3�_i r
<br /> Phone: 7�,3 -y�� -���, (office) (cell)
<br /> Mailing Address: SiyS.z'„�«,�.�,;i sG Sw. � ��3 City:/yo,,/��/o,;, ZIP:SS ?S f
<br /> Contact Person: G,�,,,,�„ 5��.�,h��s Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax: �� 3 - ��� -����
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ,�,��, .� L�e_sa �-'��-c.s,,n
<br /> Phone (day): �,d a�c, -3ys�
<br /> Address: 3a�s C�y.rf, I �',r ��1. Cit : i4A1Z��� ZIP: �S3y;
<br /> Email and/or Fax '
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review 8�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 /> e-roof ❑ Fire Damage www.minnehahacreek.orq � (
<br /> Overall Pro'ect Descri tion: a��'
<br /> , p ��,� �{f ,ce �4� �, G,�4 �i ,� r�, . ��-� ���, s ��
<br /> Estimated Construction Valuation of Project(excluding land) $ /� ��� �� �
<br /> �
<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 infor ation, the a lication ma not be issued.
<br /> ApplicanYs Signature: Date: � '""v�s' l U
<br /> Last Updated: 05-04-2009
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