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City of Orono
<br /> Building Permit Application
<br /> �—_„ Mailing Address: Permit number:
<br /> ��;0,�.� PO Box 66
<br /> '� �'
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> ��; �
<br /> ,� �'���_ �,��� StreetAddress: Received by:
<br /> ��',�,� '°��r.�,:9_ �ti!% 2750 Kelley Parkway Plan review fee:
<br /> kESHoY�`� Orono, MN 55356
<br /> ��—_' Total Fee:
<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: ��?r,? � �'�.n��',.� 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 Counci/approva/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 I APPLICANT INFORMATION:
<br /> Name: �/,�"., �S",rz �.E _r
<br /> State License# � / �� � Expiration Date: �/,,•�j/��,
<br /> Phone: Y,��- g3 P'�' - .S 3�� �� (office) ��-3,4 �?- ii� � (cell)
<br /> Mailing Address: �� v_� w, �y� " � .s; City: ,/�4„�� ��,�/-= ZIP: ,s',S��
<br /> Contact Person: `-� � -�� � Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax: f�, � y,�w�-,o� �c S - �o ..,, y�-�- ���; -�� yg
<br /> PROPERTY OWNER INFORMATION:
<br /> �
<br /> Name: r � /-z� ����o.�.
<br /> Phone (day):
<br /> Address: 1�r2 u ��.���j-,,, �r— City: 6 2,� ,,rio ZIP: �s����
<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: �,��,�� �,,,ti �a,,,, �,, �,� ,�,� ��� _,z
<br /> Estimated Construction Valuation of Project(excluding land) $ ��9�, o�
<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 /> required by law. If you refuse to supply the information,the application may not be issued.
<br /> ,--���
<br /> ApplicanYs Signature: / � j_���, Date: ���''
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