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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 /> � ; � Crystal Bay, MN 55323-0066 Date received:
<br /> ; `�
<br /> ��� �'�'��»;� s, � S t r e e t A d d r e s s: Received by:
<br /> s e,�
<br /> ��'.F, � �`� �ti 2750 Kelley Parkway Plan review fee:
<br /> ��kESH�4'� 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: �'�� �� �n �l �jJ` '
<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 required with Police Department and City Council approval 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: ,�//s��._ ��.ti _rl�u���F:-,
<br /> State License# �u-y 3�s?5 Expiration Date: 3-.�� —�1
<br /> Phone: ��3-y�q- ���c, (office) (cell)
<br /> Mailing Address: S�y� ��,c.ustti�.,/ �. .S.-;C--,-, /v.3 City: ��"��,� �'/.,,.,, ZIP: �J��`;
<br /> Contact Person: � , ,� Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax: �L 3_ y 7 y - �,L o� p u ?
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �p{r.:, ���✓.��f .�, r�.-�
<br /> Phone (daY): �.�-`�'�5 -�����
<br /> Address: ��c ���,�„�, t?Q City: v�t ,,� �� ZIP:
<br /> Email and/or Fax � f
<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) ❑ 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 /> verall Project Description: �,,,` �{� /'�/��;,,� �j� �;, ;n ��, , �,LQ � )
<br /> Estimated Construction Valuation of Project (excluding land) $ �� ��,�, �'"
<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 inform i , the a lication ma not be issued.
<br /> C �°��
<br /> Applicant's Signature: � v' Date: ti,�- ��
<br /> Last Updated: 05-04-2009
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