Laserfiche WebLink
Cifiy of Orono <br /> Building Permit Applica�tion for In�e�rnal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �O Meilinq Addrs�s: <br /> "¢► �T PO Box 66 Pprmit nwrnber; ��/..� 3 <br /> � Q Crystal Bay, MN 55323-0086 Date�eceived; 7 / / <br /> � ,4: � Street Address Recelved by; _ <br /> 2750 Kelley Parkway <br /> �x'� a'�" Orono, MN 55356 p��n revieriv feo: ^ <br /> �—� <br /> Mairr 952-249-4600 �ax: 952,249-4616 _ ,ci.orono.mn us Total F�e; C��' /_}� <br /> fov <br /> This applicatloh form must be completed in full and all required information must be submitted. <br /> Incomplete appllcations will ba returned. (P/ease print) <br /> GENERAL INFORMATION��� <br /> Job Site Address: O � <br /> Will thls be a Parads of Homes, Remodelers Showcase Wome or other Display Home? yo$ <br /> lf,yps,s speci�l evenf pamtit is required wlth po�/�pepartn�ent and City Councll spproval 60 days pilor rp the event. Shutt/o Dus senrice'w�l be <br /> raqulred unless appllcent demoqstr�tea sufl7clent on-site psiklrtg is available, Non permltted evonts wAl not bo allowed. <br /> cONTRACTOR� �ICANT INFO MATroN: <br /> Name; ' 1 <br /> State License� <br /> `�� Expiration Date: <br /> L.ead Certffication Number: <br /> (fo�work on homos that we,�consfructod prior to 1975 ExPiration Date; <br /> Phone� ��✓�— ��/, �G(�'� (office) p`o�_ ��(�_ �P,� � (cell ' <br /> M�iling Address: - - ` ) <br /> Contact Person� • � ���y� ZIP; ���� <br /> pplicant is: ontrac or / Homeowner (Clrclo One) <br /> Email and/or Fax: �L <br /> � ' —� ° c.�i�1- <br /> — ''�'7�'1 <br /> PROPERTY OVIINER INFORMATIOIV: <br /> Name: ' �� �,. � � e. <br /> Phone(day): S�_�r�a_ � c�D/Z� <br /> Address: ���U—��—�. City; <br /> Email and/or Fax ZIP: <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑Remodel ❑water bamag� MCIND review s�permlts: <br /> ❑Window(s) ❑ Re air Minnehaha Cre�k Watershed Dlstrict(MCWD) <br /> P �Storm Damage 18207.Minnetonka Blvd <br /> ❑Siding ❑Restor�tion �Other; {speclfy) Deeph�ven,MN �5391 <br /> Re-roof C]Fire Damago Phono� 952-471-0590 <br /> Fax: 952-471-0682 <br /> wvuw.minn�hahacre�ek or4 <br /> Overall Project Description: - ,� <br /> Estimated Construction Valuatlon of Project(excluding land) $ --� <br /> —�--.�� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • l�grees to provide all information required or requested by the Building bepartment; �� <br /> • Certifies that the information supplied is true and correct to thF best of his/her knowledge. The applicant recognizes that they <br /> ar�solely responelble for submitting a complete application being awaro that upon failure to do so, the staff has no alternative <br /> but to reject it until it is compfete; <br /> • Some or all of the Informatlon that you are asked to provide on thia application Is classlfied by State law as either private or <br /> confidential. Private data is Inform�tion which genorally cannot be given to th� public but can be given to the sub)ect of the <br /> data. Confidentit�l data Is information which generally cannot be glven to eith�r the public or the Subject of the data. Our <br /> purpose and intend�d use of thls information is to annually update our records and records af other gov�rnmental agencies <br /> re uired b law. If ou refuse to su I,the Information, the ap licetion may not be issued. <br /> Applicarlt's Signature; �� c,� /�', �J Date: �'Ic�-"-� � <br /> I.ast Updatod: 03-01-z011 <br />