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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: /� � a-- C�
<br /> �i:��3,�. �i
<br /> ,� ����,��4�`��, ,, i Street Address: Received by:
<br /> �',�, '� '9`� �ti 2750 Kelley Parkway Plan review fee:
<br /> r9kESH��'� Orono, MN 55356
<br /> - Total Fee: �7�; �
<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�( ���,'J�'��E�� (t �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o
<br /> If yes, a special event permit is required with Police Department and City Council approva160 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 INFORMATION: ,
<br /> Name: L�S���e �b.v s�fZ.�,ct`r a�-,
<br /> State License# a o�, 3 i S7� Expiration Date: �3 3,� �zo �-L---
<br /> Phone: (�3- %���i— � � office cell
<br /> Mailing Address: ���,� :.�u, �,�� S r— Cit : �- ,�-,," ZIP: ,j 3� ��
<br /> Contact Person: . '�,� S ��,;,.; Applicant is: ntrac / Homeowner (Circle One)
<br /> Email and/or Fax: ,�,�,� �� uST�1-2-ta a �t�, • C�,.�-�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: f`�v, �.; I�/�(���N �
<br /> Phone (day): �s�. � �c/- ��o �>
<br /> Address 7 g� �.��N�,3('�z �Q City:l,(,'�-v��,�=�y� ZIP: �3`� /
<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 /> �e-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ 7J� �;x� "=
<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 /> ,-�� �
<br /> ApplicanYs Signature: /�� ���- Date: ���1 z-�Io
<br /> / �
<br /> c __.. -
<br /> Last Updated: 05-04-2009
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