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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: ���O—UO j0
<br /> �,0,� PO Box 66
<br /> � � � �
<br /> Crystal Bay, MN 55323-0066 Date received: �� ���'D
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<br /> � 5��:!`e�.I`�:.
<br /> a ��:-`=s,~;�, s. � StreefAddress: Received by:
<br /> �'�t.y��rti��`�rv°~�l 2750 Kelley Parkway Plan review fee:
<br /> kESH�g' Orono, MN 55356
<br /> Total Fee: � //�,��j, �J`�
<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 INFORMATION: �
<br /> Job Site Address: �_,��7 ;�� ,� ,f, i, �„,: /".%...4 ��,
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �1Vo
<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 avaifable. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: /� //;�,,.- � � .
<br /> State License# ,�`;�, 3, s �_% Expiration Date: � -,Y�- i �-
<br /> Phone: (,3�� 7 - ��o� office) cell
<br /> Mailing Address: ��y� �,�(,,t,L _ ".> ;� ;�� Cit : ��,r - ZIP: �� "�
<br /> Contact Person: Pc ��. r,o��ls�,- Applicant is: act �/ Homeowner (CircleOne)
<br /> Email and/or Fax: ��,,,? _ ��� _�, � ,,��
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: _ --� ' �� :�
<br /> Phone (day): c;, �z � ���i 7 - ��r 4� l
<br /> Address: ;�, - �,, „ ,� ,r='� � � l —/J� �'
<br /> , ;.��-� rc ._ � �_ � �.- Cit :�ti�„.�,Z./.� ZI P� �, `,
<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 /> Fax: 952-471-0682
<br /> '�f�e-roof ❑ Fire Damage www.minnehahacreek.ora
<br /> Overall Project Description: 7=�.,, , L� ��, ji �{
<br /> Estimated Construction Valuation of Project (excluding land) $ �,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 annualty update our records and records of other governmental agencies
<br /> re uired b law. If ou refuse to su th �formation, the a lication ma not be issued.
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<br /> Applicant's Signature: 1_� Date: �(,.� � �j �.��� �
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<br /> Last Updated: 05-04-2009
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