Laserfiche WebLink
Jan. 7. 2011 10: 51AM TERRA FIRMA No. 2723 P, 2 <br /> r <br /> Cifiy of Orono <br /> � Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> —O-- Mailing Address; permlt number <br /> t � .� I � ' ` PO Box 66 ��� � <br /> Q 0 (� v l' � Crystal Bay, MN 55323-0066 Date received� d/ p. <br /> � �� i °I . <br /> � h 5treetAddress� Rer.eived by' <br /> e 2750 Kelley Parkway Plan review fee: <br /> ��'Esx� ' Orono, MN 55358 D� ` <br /> M in: 852-249�600 Fax; 852-249-4616 www,ci,orono.mn.us TOtaf Fee: ,��8', <br /> is appficatio form must be completed in full and all required information must be submitted. <br /> � IncompleEe applications will be returned. (Please print) <br /> G�NERAL INFORMATION: <br /> Job Site Address: y y � �.r u �..� c, <br /> Will this be a Parade �f Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> If y�s,a special event permlt is roqulrsd wlth Pollce Department end City Council approval 60 days prior ro the event Shuttle bus service will b <br /> required un/ess applicanf demonstr�fes su�cient on�ite parking is availabJe. Non-permitted evenls will not be allowed. <br /> CONTRACTOR/APPLICA�IT IN�F1ORMATION: <br /> Name: J_'�1a /^7 �/ Al���I�C.� frnr�' ' /!�r'C �� �� I,' �� ��11C Q. \E� �L@ +�f � � i <br /> State License#� av�i/ y C�/ Expiration Date: 3.. ,�1- �� <br /> Phone: �5 �-� �o j. C u ��o (office) 51- �v a s5��S (cell) <br /> Mailin�g Address: ,3� y,o �., _ Cit : -t ���;�,.r ZIP:�, �� <br /> Cont�ct Person: - Applicant is: ontractor / Homeowner �c�rua oha� <br /> Email and/or Fax� .t �� . .��. _ <br /> PROP�RTY OWNER INFORMAI'ION: <br /> ame: �'�,-�, C�;I� :, �,, i 7� 5 If�r <br /> hone(daY)' G�.Z- .���19-. �vi�t <br /> ddress: 15 3 i/� , �• � .�,,�., A �� S Citv-(.�����t� ZIP- �?�3�i <br /> Email and/or Fax �iK,;�i 5�,,, �;.,��T C__ C C�M -"' <br />� � <br /> PROJECT INFORMATION; <br /> Type of Project: , Any earth movement may�quire <br /> MCWO review 8�.permibs <br /> [] Door(s) Remodel ❑Water Damage <br /> ❑Window(s) ❑Rep ir ❑Storm Dama e Minnehaha Creek Watershed District(MCWD) <br /> 9 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> � Siding ❑ Rest ration ❑ Other: (speciiyj Phone: 952�71-0590 <br /> ❑Re-roof Fax: 852-471-0682 <br /> ❑ Fire Damage www.minnehahacreek_ora <br /> Overall Project Description; ,��f,�,�o�� ren Va o� wtio% �i��� �,%�hn -r ; � � �P /�<e �ov.� <br /> Esti ated Construction Valu ion of Project(excluding land) $ 3�ppp ' <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agre�s 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 appficant 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 r�aject it until it is complete; <br /> • Some a all of the information that you are asked to provide on thi5 applic2tion is clessified by State law as either private or <br /> i confider�al. 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 recvrds and records of other governmental agencies <br /> re uired b law. If ou rafuse to su I the inform tion,the a lication ma not be issued, <br /> 1 � <br /> ApplicanYs Sig ture: Date: l���✓r'�� <br /> � <br />