Laserfiche WebLink
� ' � City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> �,� PO Box 66 <br /> (Q .,` O Crystal Bay, MN 55323-0066 Date received: <br /> ��.�,..�. i <br /> �' �'�`�•-�' �,'i StreetAddress: Received by: <br /> � � �? �,�>�- , <br /> �'� �" Gti 2750 Kelley Parkway Plan review fee: <br /> t�kESHo¢'�/ Orono, MN 55356 <br /> � <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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ;`-� I �Acl���z z;z`/ �1 • l l ;�Z�c.;L� <br /> Will this be a Parade of Homes, Remodelers S owcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required with Police Departmenf 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 wi!l not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: No�Z�JF��A �,,,s v�-�~c � �-1,C. � <br /> State License# O� � 3 �'i Z� Expiration Date: 3�3/- JD <br /> Phone: 1�3 - ZnC� � - �-1 �`-I S (office) (cell) <br /> Mailing Address: 1(3� i S� ��R �, � Cit : r4,v;�c���Z ZIP: S��.�c� <br /> Contact Person: �j�,bio�; U 15c.�� Applicant is: ontrac o / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: (Y1 � k` iMu� ��'��►vy <br /> Phone (day): l�1 Z , �c� 1 - 5 tFc��, <br /> Address: 1yt �-�r����.�c�z�, ��. \� City: p�z���:,u ZIP: Ss 3S�(�% <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: <br /> Estimated Construction Valuation of Project(excluding land) $ Q,.�Y_,(� <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 /> ApplicanYs Signature: ��n �✓�.�j• ,�,�,�,,L,,., �^ Date: I���� . 3(� Z(�G`ti <br /> Last Updated: 05-04-2009 <br />