Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
DE�-3-2G�:.0 �3:40 FROM:TREBILFOUNDATION SYS 3205938720 T0: 19522494616 P.3�3 <br /> City o# Orono <br /> Buiiding Permit Application for Internal Work <br /> (windows, doors, siding, �e-roof, etc.) <br /> r��, MailinpAddiess: Permitnumber; �l —�� <br /> Q��,�0 PO Box�6 <br /> Crystal Bay, MN 55323-0066 Dete rocoived; i � .D D <br /> � ,�' � Street Address: <br /> Received by: <br /> 2750 Kelley Parkwey Plan review fee: <br /> ��;� $ Orono, MN 55356 <br /> \�+Ar 4. <br /> �=-�" ���d <br /> Tot�l,Fee:, <br /> Main, 952-249-4600 Fax= 952-249-4616 www,ci,orpnp.mn.us <br /> This applicakion form must be completed in full and all required informaticn must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ��,�c n� r� � r�v <br /> Will this be a Parade of Homes, Remodelers Showcase Mome or other Display Home? Yes No <br /> !/yos,a speclel event permit is requlrod wlth Pol�Ce DepeRment and Clry Councll epprvvu/60 deys prlor!o the evant. Shuttle 6us aarolce will De <br /> requirod unless appdcant damonsfretea sW/Iclent oa-s!ro perking Is evsllable. Non peimllted events w/ll nor bv allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Neme: 'S�_��.��T� ,�.� C���5\�.�icK� ���,i�,�e,�,-.c-� 'C`'n� <br /> State License# _ �r,�l_y(r,y. $ �, T____. _ Expir'ation Date: �-3�- o?_O\7.__ <br /> Phone: � P= � offica cell <br /> Mailing Address: -� ��_ Cit � ZIP: Sr�3 <br /> Contact Person: � , Applicant is; r�3. Momeowner �ci.ci.o�a) <br /> Email and/or F�� � a <br /> PROPERTY OWNER INFORMATION: <br /> Name: � �r <br /> PhOne (day): - r - � - <br /> Address' �� � Cit ZIP: .�� <br /> Email and/or Fax <br /> PROJEC7 INFORMAtION: <br /> 7ype of Project: Any earth mcvemant m�y requlre <br /> MCWD rovlew&permlts <br /> �Door(s) ❑ Remodal ❑Water Damege <br /> Minnehaha Creek Watershed Qfstrict(MCWD} <br /> ❑Window(s) []Rep�ir ❑ Storm Damaga 19202 Minnetonka 6lvd <br /> Oeephaven, MN 55381. <br /> ❑Siding ❑ Rastoration �Other: (specify) Phone: 952-�71-�590 <br /> 3�,\,••ea� ���+ C�r c„ �1 ���� Fax: A62�a71-0682 <br /> ❑ Re-roof ❑ Flre D2m2�s - � www.minnAhahacrR9k.ora <br /> Overall Pro ect Deacrlptlon: <br /> Estimated Constructlon Valuatlen of ProJect�excluding land) $ ��-,r �(a ��Q <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide all inFormation required or requested by the Building DepaRmenC; <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 Por submitting a complete epplication being aw8re that upon fd(lure Co do so, the staff hes no alternative <br /> but to rejeCt it until it is complete; <br /> � Some or atl of the information that you are aeked to provide on thie appllcation ie claseified by State law as either private or <br /> confidential. Private data is informakion which generelly cennor be given to the publlc but can be given to the subject of the <br /> data. Confidential data is informati�n which generally cannot be given to either the public or the subject of tha deta. Our <br /> purpose and intended use of this infofinetion is to annually update our records and �ecord� of oth�er governmental agencies <br /> re uired b lew. If ou refuse to su I the information the e licetion me not be issued, <br /> Applicant's Signature: ���Q,� �p���� Data; ��„ .,.,,,.Q.,�n 3 ,T C�� <br /> '�eQ.,..�.a--,J.,�,.e.�,.,�.� C'�a�.��a,.� <br /> Last Updata0: O�Oa-Z009 <br />