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� ' City of Orono
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> �v�,(� �a//rP0 B xr66 . Permit number. ���— (�
<br /> II � N� O Crystal Bay, MIV 55323-0066 Date received:
<br /> �,� ! �i b, a,� S t r e e t A d d r e s s: Received by:
<br /> .� � ���'� 2750 Kelle y Parkwa y P l a n r e v i e w f e :
<br /> '��sg��ag'� Orono, MN 55356
<br /> Total Fee: �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ��� � C�
<br /> �
<br /> This application form must be completed in full and all required information must be subrrtitted.
<br /> Incomplete applications will be returned. (PJease printJ
<br /> GENERAL INFORJ111ATION:
<br /> Job Site Address: ���-� �,,��,��,,;_. ��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes IVo ^
<br /> liyes, a special event permit is requlred with Police Depa►tment and City Courtci!approva160 days prior to the event. Shutt/s bus se�vice wiR be
<br /> required unless applicant demonstrates safficient on-site parking rs available. Non-permitted events w�?1 not be allowed.
<br /> COHTRACTOR/ LICANT INFO ATION:
<br /> Name: � ���� �
<br /> State License# Z , Expiration Date:
<br /> Lead Certification Number: �,�� ,����'Z— Expiration Date: —
<br /> (for work on homes that were constrvcted prior to 1978
<br /> Phone: � E��.--6�2',�,[...C�`�,te�, (otfice) G�,�t ^' ,3,_ 'ae O'� (celq
<br /> Mailing Address: -�-�, ��*�+� �, �_, . ,,� Cit • . P�� ZIP: fv�� "��L�;
<br /> Contact Person: ,r,,. , _ . .� Applicant is: Contractor', / Homeowner (Circle One)
<br /> Email and/or Fax: c�,��,�$�Wi , �,.;�,,..,a�,r� —�6`nc�-�t��a , r� �n C . t,Z. �Z,� rC2�
<br /> PROPERTY OWNER INFORMA7I�N:
<br /> Name: ��9� �d LS;,v
<br /> Phone(day): (�iZ Z4� . `��t\'S
<br /> Addfess: �`b a.� ��i�.t��� r �,�3 Clty: �bE�.,� ZIP' �y�'�.��Cc�
<br /> Email and/or Fax �*,�,� �,�,
<br /> PROJECT INFORMATION:
<br />� Type of Project: Any earth movement may require
<br /> ❑ Door{s) ❑ Remadel ❑Water Qamage �CWD review�permits:
<br /> Minnehaha Creek Watershed District(MCWD�
<br /> ❑Window(s) ` �Repair �Storm Damage �8202 Minnetonka Blvd
<br /> ❑Siding ❑Restoration ❑ Other: (spe�ify) Deephaven, MN 55391
<br /> �Re-roof Phone; 952-471-�590
<br /> ❑ Fire damage Fax: 952-471-0682
<br /> uvww,m inneh a ha creek.orq
<br /> Overafl Project Description�'�_ t,,c,G � ��-,- ._�,cc ! +�,'��, ,r ,��� C�-��;,�_ ���,��
<br /> Estimated Constructian Val�atian of Pro'ect excludin land $ � '"'�
<br /> J { 9 1 `1�, 1 t��-. �.�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide al�informati�n required or requested by the Building Department;
<br /> • Certifies tE�at the information supplied is true and correct to the best oF hislher knowledge. The applicanl recognizes that they
<br /> are solely responsible for submitting a complete application being aware that upon failure to do s�, the staff has no alternative �
<br /> but to reject it until it is complete;
<br /> • Some or all of the information ihat you are asked to provide on this application Es classified by State law as either private �r
<br /> confidential. Private data is information which ge Ily cannot be given to the public but can be given to the subject of the
<br /> da�a. Confidential d a information w ich gen all c not be given to either the public or if�e subject of the data. Our
<br /> purpose and intende us of this inform ion is t ann ll update our records and records of other.governmental agencies
<br /> re uired b law. If u ref�se to su I t 'nfarm ion,th lication ma not be issued. '
<br /> � �
<br /> ApplicanYs Signature: Date: � � � �
<br /> Lasi Updated: a3-01-2011
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