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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 /> O�,�,�.0 PO Box 66
<br /> � Crystal Bay, MN 55323-0066 Date received:
<br /> ���_ -
<br /> '�' I Received by:
<br /> a � �, . _ �, Street Address:
<br /> �'�,t' � &�y��ti``' 2750 Kelley Parkway Plan review fee:
<br /> .�x.E$xog Orono, MN 55356
<br /> _—' Total Fee:
<br /> Main: 952-249�600 Fax: 952-249-4616 �P✓ww 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. (P/ease print)
<br /> GENERAL INFORMATION• � /
<br /> Job Site Address: ���� rC��-'�t� `-E�-Z
<br /> Will this be a Parade of Homes, emodelers 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�FORMATIQN: � , /' �
<br /> Name: �c.v►7 S;t� ��?S r�r:�i. �l.'�-, l.> �`thhx- ���'! �.
<br /> State License# ,,2�3 �7 5 p� Expiration Date: �-/3' /3
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were consfructe prior to 1978
<br /> Phone: 7��- SY�,--//f� (office) � �Z --`,d`,�' � " // �,;{� (cell)
<br /> Mailing Address: ,;��i /"-1 �,,� SS Scs,' .z S"��,v City: i� /,�f ZIP: �„s��'� Z
<br /> Contact Person: � -� Applicant is: on rac or / Homeowner (Circle One)
<br /> Email and/or Fax: ,,��-p�,t,J, � ��,,, - �c , �.,�Try,
<br /> PROPERTY OWNER INFORMATIO�I�
<br /> Name: /�a.-nc-r� /S,ct,/�i.r
<br /> Phone(day): (,,�/ -�:Z y 7 -/S(,c�
<br /> Address: 3ps'� F4..r U,y�%,v City: (�r0�'lp ZIP:�5�.3.S�v
<br /> Email and/or Fax k��,k�� /3 r 7@ c:�o/. �-�'��
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel Water Damage MCWD review 8�permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) �Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> f�Siding ❑ Restoration ❑Other:(specify) Deephaven, MN 55391
<br /> Phone: 952�71-0590
<br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682
<br /> www.minnehahacreek orq
<br /> Overall Project Description: t-�rt+o�c- s f�_c�,o wr� /7�,6��i+2.*-r'-r-% r�.c o : >s �'C • ��
<br /> Estimated Construction Valuation of Pro ject(excludin g land) $ C p� ,yJ, � �4�
<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 t u the' for tion,the a lication ma not be issued.
<br /> ApplicanYs Signature: Date: �O`v� 7" 1 �
<br /> Last Updated: 03-01-2011
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