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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: D L�-�l°�
<br /> ,,��,�,�:�� PO Box 66
<br /> O O,', Crystal Bay, MN 55323-0066 Date received: � ,3� ��
<br /> , Received by: ��
<br /> a �, r� �, StreetAddress:
<br /> �;�'�, ��'�r��ti,� �ti;i 2750 Kelley Parkway Plan reviewfee: � � ' �y�
<br /> ��'�kE's'xo��'� Orono, MN 55356
<br /> - Total Fee: 3 - �
<br /> Mam: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �� `�r �
<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: � *'� �� f�
<br /> �>> �,-t �n��lc.7�c'-
<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 sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATfON:
<br /> Name: :��t���,��.�;��:� (_.i_<�
<br /> State License# �p���{��3 i; Expiration Date: 3j;�jz,��
<br /> Phone: �i oL- 6��7- ��-ib (office) `i J�-;`1�-71 Sv (cell)
<br /> Mailing Address: � �„�. �•_y�, /?r��' Cit : �,� ,�11- - ZIP: �:,;� 7, '
<br /> Contact Person: �"",,;.�f, (�,._��_, Applicant is: ontrac o / Homeowner (CircleOne)
<br /> Email and/or Fax: � �,;,�,,��{�,,zJ�,,,,�:. �,��.,
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: � T: , '�i> ���-.�> Sr,��yr
<br /> Phone (day): ^
<br /> Address: ']3S �'�r,��.l.,= �1 r„� Cit,: ���cv�� ZIP: j`,��-
<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 /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description: j�-}:ri,� -C
<br /> �� . �:t11')'�k�lo.� J� 1����;,n T (00(_ �� flJz�J t,k'�i����� �i�i.�: �" ���"I,c,�7
<br /> Estimated Construction Valuation of Project(excluding land) $ ���.J,�,�
<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 to su I the information,the a lication ma not be issued.
<br /> Applicant's Signature: Date: (2 3� �J
<br /> Last Updated: 05-04-2009
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