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<br /> City of Orono
<br /> � Building Permit Application
<br /> Mailing Address:
<br /> ��g,�,j�.\ PO Box 66 Permit number. 2--CC%�' - CC:% (�:�7
<br /> ` � 1 Crystal Bay, MN 55323-0066 Date received: —1 � 'GG1
<br /> �� � Received b
<br /> (,a ���� s.� Street Address: Y�
<br /> �r~
<br /> �'.�c,L G� 2750 Kelley Parkway Plan review fee: ,.�
<br /> 9kE�rv Orono, MN 55356
<br /> �---� Total Fee: ; /G ��
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �7 O
<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: ��'j(,,�L� E�,�;, ��„� 'rYo„� (�Yo��,,
<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 su�cient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �.�r;:>��1 �,:.��>�r,:t-j�. ��co�n Zr� -
<br /> State License# , � �� �, ,�, Expiration Date: ��/���
<br /> Phone: ��3 S�it�.I I� (o�ce) 1�. �t /1��� (cell)
<br /> Mailing Address: � , �x,r, Ci : � � ZIP: ���i�s.�
<br /> Contact Person: Y1ti..,� ,a,t Applicant is: on ra / Homeowner (Circle One)
<br /> Email and/or Fax: y�,�r,,..o,t.t� r, C�v�y� l„ ��,�.v-a �___
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: y 'c,��c. a P��,.>� �c 5��-.
<br /> Phone(day): ��S�.���.;�5/
<br /> Address �� City: ZIP:
<br /> Email and/or Fax �2�� � �1'►'� �? ✓�C ti s.' , �I,rv�
<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) epair c�-�„�;� ❑Storm Damage 18202 Minnetonka Blvd
<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.orp
<br /> Overall Project Description: j;k n.}I�-�►�.�( S<n�a.�_ c� �;.t-,�
<br /> Estimated Construction Valuation of Project(excluding land) $ � �,,,�, ����
<br /> APPLICANT ACKNOWLEDGEMENT: J
<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 knowled� � s?� �
<br /> are solely responsible for submitting a complete application being aware that upon fail� e
<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 �a.. or
<br /> confidential. Private data is information which generally cannot be given to the public but can be given to the suo�c.,, _ 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 /> required by law. If you refuse to supply the information,the application may not be issued.
<br /> Applicant's Signature: , ��� Date: y �� ��c">
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<br /> Reset Form
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