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<br /> City of Orono
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> /�_\, Mailing Address: Permit number: � —O� `�'J�3
<br /> ��,�,�.� PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: 7� O
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<br /> a ;;�, s.�� Street Address: Received by:
<br /> �'�,� � ��� ��� Gti 2750 Kelley Parkway Plan review fee:
<br /> �kESH�4'� Orono, MN 55356
<br /> Total Fee: �D5 l�
<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 INFORMATIQN: '�.
<br /> Job Site Address: ��; `>��;�,�,h �41,��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �C 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/ ,PLIC IW�ORMATIOpJ;�
<br /> Name: �Q�C:.���:°.4;ik� ��t� '.�"1�12�1,1t\�.
<br /> State License# �' ;�, ,•'� �— Expiration Date:
<br /> Phone: � `" , _ `�� o�ce `� - ��� �,l �, cell
<br /> Mailing Address: � � � �r� Cit :` � � � ^, - ZIP: --
<br /> Contact Person: `' � �r, � 'r, � -,r.S Applicant is: Ea�t�as�c. / Homeowner �c���ie o�e�
<br /> Email and/or Fax: ,- cr � � �� , ,� ;.,. -, ,. � � �,
<br /> PROPERTY OWN� INFORMATION:
<br /> Name: ` �,
<br /> Phone (day): �"��° �.�C .
<br /> Address: �' '„ �` . - Cit : ��� ZIP: � -
<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) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> ❑ Siding ❑ Restoration �Other: (specify) Phone: 952-471-0590
<br /> `1 Fax: 952-471-0682
<br /> ❑ Re-roof ❑ Fire Damage ' `� ' • ��, Lt! �•h' www.minnehahacreek.orq
<br /> Overall Project Description: � t,� ,•.
<br /> Estimated Construction Valuation of Project(excluding land) $ jy� ��
<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 information,the a lication ma not be issued.
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<br /> ApplicanYs Signature: , _ , ,: Date: _��'Z T_� G�
<br /> Last Updated: 05-04-2009 !,�I� �p �ssV(
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